As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Optical Information

Ocular History Please mark "Yes" if you have history with the following.

Medical Information

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began April 13, 2003. Many of the policies have been our practice for years. A more complete text is posted in the office. What is this all about: Specifically, there are rules and regulations on who may see or be notified of your Protected Health Information (PHI}. These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov.

We have adopted the following policies:

1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as it is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than the office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, email, U.S. mail, text message, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
4. You understand and agree to inspections of the office and review the documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods, or services.
7. We agree to provide patients with access to their records in accordance to better serve the needs of both the practice and the patient.
8. We may change, add, delete, or modify any of these provisions to better serve the needs of both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Boreing Vision Clinic is pleased to accept your insurance assignment. We offer this service as a courtesy to our patients. It must be clearly understood that the contact is between the patient and the insurance company, the account thereby being the responsibility of the patient for any amount not paid by the insurance company. The following is a statement of our policies governing insurance claims.

• All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and a current valid insurance card(s) to provide proof of insurance. If you fail to provide us with the proper insurance information in a timely manner, you will be responsible for payment in full the day of your visit.
• Although we are willing to complete insurance information forms and submit a claim on behalf of the patient, we do not accept responsibility under any circumstance for the outcome of the transaction. Completing insurance forms is a courtesy we extend to our patients in an effort to maximize their likelihood of obtaining insurance reimbursement. By having our offices process insurance forms, the patient agrees to accept the liability for those forms. Alternatively, a patient may fill out his/her own insurance form and bill the insurance directly.
• The patient will pay the co-payment (the amount not covered by the insurance company) at the time services are rendered. Our office accepts payments in the forms of cash, check, care credit, debit, Visa, MasterCard, American Express and Discover.
• Insurance payments originally are received within 30 to 60 days from the time of billing. If a patient's insurance company has not made payment to our office within 60 days, we may request the patient pay the balance due and seek reimbursement from their insurance company. Please be aware that if a balance remains unpaid for 30 days, we will refer your account to a collection agency.
• Our office does NOT guarantee that the patient's insurance company will pay. We will perform our routine insurance billing procedures upon verification of coverage. However, if for some reason the patients claim is denied, the patient is then considered to be responsible for the full amount of the bill.
• Our office will not enter into a dispute with an insurance company over any claim, although we will cooperate fully with the regulations and request of the insurance company. It will be, however, the responsibility of the patient to handle with the insurance company any type of dispute over payment by the company.

If you understand and agree to all of the above office policies, please sign your name below

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

• Contact lens fitting fee is separate from the exam copay. This fee will cover any follow-up visits within a 3-month period.
• The fitting fee price will vary based of the type of contact lens the doctor prescribes.
• The fitting fee must be paid at the time of exam and fitting.
• Prescriptions are valid for one year.
• Boxes of contacts are sold separately.

To acknowledge that you have read and understand what has been listed above please sign below.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.