Heaton Eye Associates
Adult Patient Information Sheet

Patient's Last Name First Name
Middle Initial E-Mail Address
Address / P. O. Box / Apt. # City
State Zip Code
Home Telephone Number Birth Date (month/day/year)
Age Sex
Social Security # Marital Status
Patient's Cell Phone # Birth Date (month/day/year)
Patient's Employer Name and Address
Patient's Employer Telephone Number If Retired (when and where?)
Spouse's Name Date of Birth
Age Sex
Social Security Number Spouse Cell Phone #
Spouse's Employer Name and Address
Spouse's Employer Telephone Number If Retired (when and where?)
Contact Person: Closest Friend or Relative (living at a different address)
Telephone Number
Primary Insurance Name & Policyholder:
Secondary Insurance Name & Policyholder:
Other Insurance Name & Policyholder:
I declare I have no other insurance than what is listed above:
Signature Date
Preferred Language: English Other-please list:
Ethnicity:
Race:
Are you here for a Workers' Compensation Injury?
Date of Injury:
Employer's Address:
Contact Person at your Work & Phone Number:
If referred by a Medical Doctor or Optometrist, please list:
Full Name: City:
PRIMARY CARE PHYSICIAN'S NAME (PCP):
Optometrist:
Are you interested in learning more about:

HEATON EYE ASSOCIATES

CONSENT FOR TREATMENT:   I,  by  my  signature  below, grant permission for Heaton Eye Associates to render such care that the physician may deem appropriate in my / my child's treatment and diagnosis. I agree to my I my child's eyes being dilated if the doctor determines it is necessary. I have read the NOTICE OF PRIVACY PRACTICES and have had any questions answered by this office. I understand that by signing this form I consent to the following:

  1. Sharing of information for the purposes of treatment: My health information may be used by Heaton Eye Associates or disclosed to other health care professionals for the purpose of evaluating my health, diagnosing medical conditions, coordinating and providing treatment.

  2. Sharing of information for purposes of payment: My health information may be used to seek payment from my health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that I may use to pay for services.

  3. Sharing of information for purposes of operations: My health information may be used as necessary for business purposes to support the day-to-day operations of Heaton Eye Associates (including but not limited to the credentialing process, peer review, accreditation and compliance with all federal and state laws).

I hereby assign my health plan benefits or other applicable insurance benefits for medical/surgical treatment for myself / my child to Heaton Eye Associates.

I understand that I am responsible for compliance with the standards and regulations set forth in my/my child's health care plan and further understand that I will be responsible for all deductible, non-reimbursable fees or fees for service not covered by my I my child's health care plan.

My consent is freely given. I understand that I may revoke this consent at any time if that revocation is in writing. Any use or disclosure that has already occurred prior to the date of my revocation of consent will not be affected.

Patient Name (printed) Date of Signature
Signature of Patient / Legal Guardian Relationship to Patient
Charles L. Heaton, M.D.
Jeffrey s. Hunter, M.D.
Thad D. Hardin, M.D.
Joel T. Muirhead, M.D.
Todd M. Nickel, D.O.
Adam P. Dossey, M.D.
David C. Craig, M.D.
Mark G. Lloyd, O.D
Matthew R. Marshall, O.D.

HEATON EYE ASSOCIATES' LOCATIONS:

3415 Golden Road/Tyler, TX 75701
1205 N. Sixth Street / Longview, TX 75601
1260 S. Palestine Ave. / Athens, TX 75751
1600 Highway 79 S. / Henderson, TX 75654

FINANCIAL POLICY
Heaton Eye Associates

  • PATIENTS WITH INSURANCE should understand that Heaton Eye Associates is absolutely committed to providing you with the highest level of service and quality care. As such, our primary relationship is with you and not your insurance company. While the filing of insurance claims is a courtesy we extend to our patients, all charges are vour final responsibility regardless of your insurance coverage.
  • PROOF OF INSURANCE COVERAGE IS REQUIRED AT EACH VISIT. Bring your current insurance card(s) to each visit. If you are not able to provide proof of your insurance coverage at the time of your appointment, we may have to reschedule your appointment or you may choose to make a $150 deposit toward your visit prior to seeing the doctor and we will refund/bill you once your insurance has paid for your visit. It is your responsibility to provide our office with accurate insurance information, and to notify us of any changes in your health insurance coverage. Also, please tell us of any address and/or telephone number(s) changes. Although we participate in most insurance plans, we expect our patients to know/verify the coverage of their personal insurance plan.
  • SOME INSURANCE COMPANIES (ie. Medicare Advantage Plans, PCCM Medicaid, Blue Cross 38000) REQUIRE PRIOR AUTHORIZATION AND/OR A REFERRAL from a primary care physician for ophthalmologist visits. You must obtain this BEFORE your visit. We regret that, in most situations, we cannot obtain these authorizations/referrals for you. If you need an authorization/referral but have not obtained one by your appointment time, we may need to reschedule your appointment or you may choose to make a $150 deposit toward your visit prior to seeing the doctor and we will refund/bill you once your insurance has paid for your visit.
  • CO-PAYMENTS, COINSURANCE, DEDUCTIBLES and NON-COVERED CHARGES are a part of your contract with your insurance company. Payment will be expected at the time of service, as required by your insurance company. We will accept cash, personal checks, MasterCard, VISA, DISCOVER and AMERICAN EXPRESS. If you arrive in the office unprepared to pay these required sums, we will need to reschedule your appointment.
  • WE FILE INSURANCE CLAIMS for you with Medicare, Medicaid, and insurance carriers with whom we participate. We will also make every effort to file with your 2nd and 3rd carrier for you. After your insurance company has processed your claim, any remaining amount owed by you is due within thirty (30) days. If your insurance company does not respond to our claims, we may ask for your assistance before transferring the financial responsibility to you.
  • WE DO NOT PARTICIPATE IN VISION PLANS such as VSP, EyeMed, Cole Vision, etc.. If you have questions, talk to one of our insurance representatives.
  • CHARGES FOR A PATIENT VISIT can vary greatly based on your medical history, the reason for your visit, and any special testing requested by your doctor.
  • PATIENTS WITHOUT INSURANCE (SELF-PAY) are expected to pay $150 for their exam (including refraction) prior to seeing the doctor. If any additional testing is required, that balance is due at checkout. We offer a 20% discount for the payment of your full medical balance (excludes LASIK exams, LASIK surgery, and premium lens) with cash, check or credit card.
  • TREATMENT FOR A WORK RELATED INJURY (WORKERS COMPENSATION) must have prior authorization from your employer and/or most probably from the insurance company providing your employer's Workers Comp coverage.
  • A REFRACTION is a test to measure your best possible vision. A refraction is a required test for a complete exam and must be performed before any treatment/prescription can be initiated for your vision improvement. Medicare, Medicare Advantage Plans, QMB Medicaid, and most commercial insurance companies consider refractions a necessary but non-covered charge. If your exam includes refraction, our refraction fee will be collected at the time of your visit.
  • FINANCING is available to qualified patients through GE Care Credit for exams/procedures that exceed $250. If you require financing, please request that one of our representatives explain your financing options and the application process prior to your appointment.

ADDITIONAL FINANCIAL POLICIES include:

  • a $30.00 charge for NSF checks.
  • a $25.00 charge for a personal copy of your medical records.


I, , have read the above FINANCIAL POLICY in full. I understand and agree to comply with the FINANCIAL POLICIES of Heaton Eye Associates. I authorize Heaton Eye Associates to release any medical information needed for insurance claims submission, and I assign to it the insurance payment for its services. I understand that I am financially responsible for charges not covered by insurance.

(Updated 6/11/12)

Signed: Dated:

HEATON EYE ASSOCIATES
HIPAA ACCESS FORM FOR PROTECTED HEALTH INFORMATION


I, understand that it is the policy of Heaton Eye Associates to restrict access to my Protected Health Information. My health information may be disclosed to caregiver(s) providing health services, insurance company(ies) for payment of my claim, and basic healthcare operations such as precertification, referrals, etc. I give my permission for the following person(s) to have access (as indicated below) to my Private Health Information.

INFORMATION ACCESS PREFERENCES
Name (Please Print) Date of Birth Clinical / Surgical Financial
1
All None All None
2
All None All None
3
All None All None
4
All None All None
5
All None All None

Communication:

We will leave confidential clinical and/or surgical information on your answering machine, voice mail or cell phone.

We will use all means of communication including but not limited to email and texting unless otherwise specified.

If you do not consent to the above communication, you must specify how we may contact you:

Patient / Legal Guardian Signature Date

Medical Information

Past Personal History:

Do you wear Glasses? Yes Type: No
Do you wear Contacts? Yes Type: No

Allergies to medications:

Eye Medications/Drops: List all eye drops or eye medications that you take including the dosage and strength.

List all other medication, vitamins and/or herbs that you take: Please include the dosage and the strength of each.

Personal Medical History:
Have you been diagnosed with any of the following?

Blindness Diabetes Glaucoma
High Blood Pressure Cataracts Heart Disease
Retinal Disorder Asthma Crossed Eyes/Strabismus
Thyroid Disease Lazy Eye/Amblyopia Autoimmune  Disorders
Cancer  Other

List previous eye surgeries along with other surgeries:

Family Medical History:
Please check all that apply and indicate their relationship to you.

Blindness Diabetes Glaucoma
High Blood Pressure Cataracts Heart Disease
Retinal Disorder Asthma Crossed Eyes/Strabismus
Thyroid Disease Lazy Eye/Amblyopia Autoimmune  Disorders
Cancer  Other

Social History:

Current occupation:

Do you drink alcohol?

Tobacco Use: must be completed for patients 13 years and older:

Smoking status:

If you answered current or former please complete:

Type:

Packs per day:

Please list your pharmacy of choice below:

• This information will be added to your electronic medical record.

Pharmacy Name:

Address or approximate location:

Phone number:

If you plan to see the doctor for a "routine" eye exam and currently have an additional insurance plan specifically for VISION CARE, please let us know prior to your visit.

If you have any secondary or supplemental insurance, please provide that information and we will be happy to file on both policies for you.

ATTENTION CONTACT LENS PATIENTS:

A contact lens fitting is separate and in addition to your exam. Please notify us prior to your visit if you wish to receive a contact lens prescription. There is an additional charge for contact lens fittings. These services are only offered at our Longview and Henderson locations.

What is a "REFRACTION?"

A "refraction" is a test that is performed to determine your best-corrected vision. You will most likely have a refraction performed during your visit. Our charge for the refraction is $35.00 and most insurance companies, including Medicare, approve the procedure, but do NOT pay for it. Therefore you will be asked to pay for the refraction upon checkout.

We want to be sure your visit is as good as it can be. That means handling your care from the front to the back with all information necessary to give you exceptional quality. If you have any questions, please do not hesitate to let us know. We are here to serve you.

We appreciate you choosing Heaton Eye Associates for your eye care needs!