New Patient Paperwork

Patient Information

First Name:

Last Name


Address 1:

Address 2:


Date of Birth:



Marital Status:

Home Phone:

Cell Phone:

Work Phone:

Preferred Phone:



Insurance Details

Primary Insurance Details

Insurance Company:

Name of Subscriber:


Policy #:

Group #:

Policy Name:

Secondary Insurance Details

Insurance Company:

Name of Subscriber:


Policy #:

Group #:

Policy Name:





Primary Care Physician




Referral Source

How did you hear about us?

Health History Details


Reason for visit:
Referring provider:

Vision Concerns:

Are you having any of the following vision concerns?

Blurred Vision


Severe Sensitivity to Lights


Poor Night Vision

Bothersome Night Glare

Double Vision

Total Loss of Vision

Please type any additional vision concerns (if there are any)

Eyeglass Desire:

Do you have any of the following desires for your eyeglasses?

Replace uncomfortable, broken, or lost eyeglasses
Need extra eyeglasses for special activities
Interest in specific fashion or brands
Would like thinner, lighter lens
Reduction of glare
Please type any additional desire for your eyeglasses:

Health History Details (Continuation)


Are you interested in any of the following?

New contact lens fitting
New technology or more comfortable contact lenses
One-day use contact lenses
Contact lenses of a difference replacement period
Contact lenses for safe overnight wear
Corneal-reshaping contact lenses
Vision therapy
Laser vision correction
Please type any additional interests Previous:

Purchasing Plans:

Do you plan to purchase any of the following?

New eyeglasses
Prescription sunglasses
Non - prescription sunglasses
Computer eyeglasses
Reading eyeglasses
Sport eyeglasses
Please type any additional purchase needs:

Additional Health History



Additional Health History:

Past Ocular History (Kindly select all that apply)

Ocular Family History (Kindly select all that apply)

Medical Family History (Kindly select all that apply)

Are you vaccinated?

Social History


If yes, Drinking Amt

Tobacco Use:

If yes, Tobacco Amt

If yes, please Select Preference:

Smoking Status:



Employer Name:

Terms and Agreement (Page 1 of 4)

We respect our legal obligation to keep health information that might identify you private. We are obligated by law to provide you with notice of our privacy practices and abide by the policies in it. This notice describes how we protect your health information and what rights you have regarding it.

Treatment, Payment, and Health Care Operations

The most common reasons we would use or disclose your health information is for treatment, payment, or business operations. We routinely use and disclose your medical information within the office on a daily basis. We do not need specific permission to use or disclose your medical information in the following matter, although you have the right to request that we do not

Examples of how we might use or disclose health information for treatment purses might include:

  • Setting up or changing appointments including leaving messages containing no information about your personal health information with those at your home or office who may answer the phone or leaving messages on answering machines, voice mails, text or emails;
  • calling your name out in a reception room environment;
  • prescribing glasses, contact lenses, or medications as well as relaying this information to suppliers by phone, fax, or other electronic means including initial prescriptions and requests from suppliers for refills;
  • notifying you that your ophthalmic goods are ready, including leaving messages containing no personal health information with those at your home or office who may answer the phone, or leaving messages on answering machines, voice mails, text or emails;
  • referring you to another doctor for care not provided by this office;
  • obtaining copies of health information from doctors you have seen before us; discussing your care with you directly or with family or friends you have inferred or agreed may listen to 10 Information about your health;
  • sending you postcards or letters or leaving messages containing no personal health information with those at your home who may answer the phone or on answering machines, voice mails, text or emails reminding you it is time for continued care;
  • at your request, we can provide you with a copy of your medical records via secured fax, secured email, secured patient portal, or printed copies delivered in person or through the U.S. Mail.

Examples of how we might use or disclose health information for payment purposes might include:

  • Asking you about your vision or medical insurance plans or other sources of payment:
  • preparing and sending bills to your insurance provider or to you;
  • providing any information required by third-party payors in order to ensure payment for services rendered to you;
  • sending notices of payment due on your account to the person designated as a responsible party or head of household on your account with fee explanations that could include procedures performed and for what diagnosis: collecting unpaid balances either ourselves or through a collection agency, attorney, or district attorney's office. At the patient's request, we may not disclose to a health plan or health care operation information related to care that you have paid for out of pocket. This only applies to those encounters related to the care you want to be restricted and only to the extent of a disclosure not otherwise required by law.

Examples of how we might use or disclose health information for business operation5 might include:

  • Financial or billing audits;
  • internal quality assurance programs; participation in managed care plans; defense of legal matters; business planning

Terms and Agreement (Page 2 of 4)

  • certain research functions; informing you of products or services, offered by our office;
  • compliance with local, state, or federal government agencies request for Information;
  • oversight activities such as licensing of our doctors;
  • Medicare or Medicaid audits:
  • providing information regarding your vision status to the Department of Public Safety, a school nurse, or agency qualifying for disability status

Uses and Disclosures for Other Reason's Not Needing Permission
In some other limited situations, the law allows us to use or disclose your medical information without your specific permission. Most of these situations will never apply to you but they could.

  • When a state or federal law mandates that certain health information be reported for a specific purpose
  • For public health reasons, such as reporting of a contagious disease, investigations or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices
  • Disclosures to government or law authorities about victims of suspected abuse, neglect, domestic violence, or when someone is or suspected to be a victim of a crime
  • Disclosures to a medical examiner to identify a deceased person or determine the cause of death or to funeral directors to aid in burial
  • Disclosures to organizations that handle organ or tissue donations
  • Uses or disclosures for health-related research
  • Uses or disclosures to prevent a serious threat to health or safety of an individual or individuals
  • Uses or disclosures to aid military purposes or lawful national intelligence activities
  • Disclosures of de-identified information
  • Disclosures related to a workman's compensation claim
  • Disclosures of a "limited data set" for research, public health, or health care operations
  • Incidental disclosures that are an unavoidable by-product of permitted uses and disclosures
  • Disclosure of in needed in completing form from a school-related vision screening, Information to the Department of Public Safety (driver's license), information related to certification for occupational or recreational licenses such as pilots license.
  • Disclosures to business associates who perform health care operations for Limestone Eye Care LLC and who commit to respect the privacy of your information. We also require any business associate to require any sub-contractor to comply with our privacy policies.
  • Unless you object, disclosure of relevant information to family members or friends who are helping you with your care of by their allowed presence causes us to assume you approve their exposure to relevant information about your health.

Uses or Disclosures To Patient Representatives
It is the policy of Limestone Eye Care LLC for our staff to take phone calls from individuals on a patients behalf requesting information about making or changing an appointment; the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient, Limestone Eye Care LLC staff will also assist individuals on a patient's behalf in the delivery of eyeglasses, contact lenses, or other optical goods. During a telephone or in-person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient's vision or health status may be disclosed without proper patient consent. Limestone Eye Care LLC staff and doctors will also infer that if you allow another person in an examination room, treatment room, dispensary, or any business area within the office with you while testing is performed or discussions held about your vision or health care or your account that you consent to the presence of that Individual.

Terms and Agreement (Page 3 of 4)

Other Uses and Disclosures
We will not make any other uses or disclosures of your health information or uses and disclosures involving marketing unless you sign a written Authorization for Release of Identifying Health Information, the content of this authorization Is determined by applicable state and federal law. The request for signing an authorization may be Initiated by Limestone Eye Care LLC or by you as the patient. We will comply with your request if it is applicable to the federal policies regarding authorizations. If we ask you to sign an authorization, you may clecIlne to do so. If you do not sign the authorization, we may not use or disclose the information we intended to use. If you do elect to sign the authorization, you may revoke it at any time. Revocation requests must be made in writing to the Privacy Officer named at the beginning of this Notice.

Your Rights Regarding Your Health Information
The law gives you many rights regarding your personal health information.

  • You may ask us to restrict our uses and disclosures for purposes of treatment (except in emergency care), payment, or business operations. This request must be made in writing to the Privacy Officer named at the beginning of this Notice. We do not have to agree to your request but if we agree, must honor the restrictions you ask for.
  • You may ask us to communicate with you in a confidential manner. Examples might be only contacting you by telephone at your home or using some special email address. We may accommodate these requests if they are reasonable and if you agree to pay any additional cost, if any, incurred In accommodating your request. Requests for special communication requests must be made to the Privacy Officer named at the beginning of this Notice.
  • You may ask to review or get copies of your Health Information. For the most part, we are happy to provide you with the opportunity to either review or obtain a copy of your medical information, but rare situations may restrict the release of the information. In such cases, we will provide you such denial In writing. Another licensed health care practitioner chosen by Limestone Eyecare LLC may review your request and your denial. In such cases, we will abide by the outcome of that review. We ask that requests for review or copy of medical information be made in writing to the Privacy Officer named at the beginning of this Notice, but this is not a requirement. While we usually respond to these requests in just a day or so, by law we have a short period of time specified by State or Federal law to respond to your request. We may request an additional extension of time In certain situations.
  • Health care information you request copies of may be delivered to you in the format you request, The e-formats LIrneStone Eye Care LLC has approved Include secure email, an authorized Electronic Health Information System, and media supplied by Limestone Eye Care LLC.
  • You may ask us to amend or change your health care information if you think it is incorrect or incomplete. If we agree, we will make the amendment to your medical record within thirty (30) days of your written request for change sent to the Privacy Officer named at the beginning of this Notice. We will then send the corrected information to you and any other individual you feel needs a copy of the corrected information. If we do not agree, you will be notified in writing of our decision. You may then write a statement of your position and we will include it in your medical record along with any rebuttal statement we may wish to include.
  • You may request a list of any non-routine disclosures of your health information that we might have made within the past six (6) years. Routine disclosures would include those used for your treatment, payment, and business operations of Limestone Eye Care LLC. These routine disclosures will not be included in your list of disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you must pay for them in advance at a fee of $200.00 per list. We usually respond to your written request (made to the Privacy Officer named at the beginning of this Notice) within thirty (30) days but we are allowed one thirty (30) clay extension if we need the time to complete your request.
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