Optical Infinity,Inc. 860 Hebron Pkwy. #103 Lewisville, TX 75057 972-316-3937

Welcome to Optical Infinity. Thank you for choosing us for your eyecare needs.
Please take a moment to complete the following information.

Patient's First Name __________________________, Last Name _____________________________,

Preferred to be called ____________________

Street Address _________________________________________ City ___________________________,

State _______, Zip ______________

Home Phone __________________________, Work Phone _________________________ Ext.____________,

Cell Phone __________________________

Guardian _____________________________________,

Emergency Contact________________________________, Emergency Phone _________________________

How were you referred to our office?

Who were you referred you by? _______________________________

Finalcial Responsibility Agreement:
Payment for your professional service is expected to be paid at the time services are rendered. This is not negotiable. We do not participate in payment plans. If we are filing an insurance claim with your insurance company on your behalf, we will collect any applicable co-payments and charges for non-covered services from you at the time of service. Please be aware that payment from your insurance company cannot be guaranteed and benefits are not determined until your claim is processed. Therefore, you will be financially responsible for any claim that your insurance company denies.

Your signature below indicates that you have read and agree to comply with our office policies.

Your signature _________________________________, Date ________________________

Notice of HIPPA Privacy Practices:

HIPPA Privacy Policies

GENERAL RULE
We respect our legal obligation to keep health information that identifies you private.  We are obligated by law to give you notice of our privacy practices.
Generally, we cannot use your health information in our office or disclose it outside of our office without your written permission.  Sometimes the written permission will be called a consent form, and sometimes it will be called an authorization form.  The type of permission form will depend upon the kinds of uses or disclosures that are involved.  In some limited situations, the law allows or requires us to disclose your health information without either a written consent or authorization.
USES OR DISCLOSURES WITH CONSENT
We will ask you to sign a consent form allowing us to use and disclose your health information for purposes of treatment, payment, and health care operations of this office.  We are allowed to refuse to treat you if you do not sign the consent form.
We use information for treatment purposes, when, for example, we set up an appointment for you, when our technician or doctor tests your eyes, when the doctor prescribes glasses or contact lenses, when the doctor prescribes medication, when our staff helps you select and order glasses or contact lenses, when our staff helps you select and order glasses or contact lenses, vision therapy, and when we show you low vision aids.  We may disclose your health information outside of our office for treatment purposes if, for example, we refer you to another doctor or clinic for eye care or low vision aids or services, if we send a prescription for glasses or contacts to another to be filled, when we provide a prescription for medication to a pharmacist, or when we phone to let you know that your glasses or contact lenses are ready to be picked up.  Sometimes we may ask for copies of your health information from another professional that you may have seen before us.
We use your health information for payment purposes when, for example, our staff asks you about health or vision care plans that you may belong to, or about other sources of payment for our services, when we prepare bills to send to you or your health or vision care plan, when we process payment by credit card, and when we try to collect unpaid amounts due.  
We may disclose your health information outside of our office for payment purposes when, for example, bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan, or when we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due.
We use and disclose your health information for health care operations in a number of ways.  Health care operations means those administrative and managerial functions that we have to do in order to run our office.  We may use or disclose your health information, for example, for financial or billing audits, for internal quality assurance, for personnel decisions, to enable our doctors to participate in managed care plans, for the defense of legal matters, to develop business plans, for fundraising activities, and for outside storage of our records.

USES AND DISCLOSURES WITHOUT CONSENT OR AUTHORIZATION
In some limited situations, the law allows or requires us to use or disclose your health information without your permission.  Not all of these situations will apply to us; some may never come up at our office at all.  Such uses or disclosures are:
1. when a state or federal law mandates that certain health information be reported for a specific purpose; 
2. for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the Food and Drug Administration regarding drugs or medical devices; 
3. disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; 
4. uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws; 
5. disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies; 
6. disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; 
7. disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; 
8. uses or disclosures for health related research; 
9. uses and disclosures to prevent a serious threat to health or safety; 
10. uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service; 
11. disclosures relating to worker’s compensation programs; 
12. disclosures to business associates who perform health care operations for us and who agree to keep your health information private.

APPOINTMENT REMINDERS
We may call to remind you of scheduled appointments.  We may also call to notify you of other treatments or services available at our office that might help you.

OTHER DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written authorization form.  You do not have to sign such a form.  If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information.  You can:
1. ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations.  We do not have to agree to do this, but if we agree, we must honor the restrictions that you want.   
2. ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using e-mail to your personal e-Mail address.  We will accommodate these requests if they are reasonable, and if you pay us for any extra cost.   
3. ask to see or to get photocopies of your health information.  By law, there are a few limited situations in which we can refuse to permit access or copying.  For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us.  You may have to pay for photocopies in advance.  If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally required.  By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension.  
4. ask us to amend your health information if you think that it is incorrect or incomplete.  If we agree, we will amend the information within 60 days from when you ask us.  We will send the corrected information to persons who we know got the wrong information, and others that you specify.  If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write.  Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information.  By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension.   
5. get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want), except disclosures for purposes of treatment, payment or health care operations and some other limited disclosures.  You are entitled to one such list per year without charge.  If you want more frequent lists, you will have to pay for them in advance.  We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing.   
6. get additional paper copies of this Notice of Privacy Practices upon request, no matter whether you got one electronically or in paper form already

OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it.  We reserve the right to change this notice at any time in compliance with and as allowed by law.  If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future.  If we change our Notice of Privacy Practices, we will post the new notice in our office and have copies available in our office.

I acknowledge I have read Optical Infinity, Inc.'s Notice of Privacy Policies.

Signature ______________________________ Date _______________________

Health History:

What is the main reason for today's exam?________________________________________________

When was your last eye exam? __________________________

When was your last Physical exam? ________________________

Past Illness or Injuries: __________________________________________________________________

Past Surgeries:

Surgeries	Date of Surgeries	Surgeries	Date of Surgeries

Current Medication:

Name of Medication	For	Dosage

Current Eye Drops:

Name of Eye Drops	For	Dosage

Drug Allergies (Please list any)_______________________________________

Symptoms of Drug Allergies _______________________________________

Specific Allergies (mold, pollen, gras, etc.)_______________________________________

Eye History:

Glaucoma	Yes, No	Dryness	Yes, No	Strabismus (Crossed Eye)	Yes, No
Cataract(s)	Yes, No	Excess Tearing	Yes, No	Blurred Vision Distance	Yes, No
Macular Degeneration	Yes, No	Eye Pain or Soreness	Yes, No	Blurred Vision Near	Yes, No
Retinal Detachment	Yes, No	Foreign Body Sensation	Yes, No	Distorted Vision	Yes, No
Color Blindness	Yes, No	Infection of Eye or Lid	Yes, No	Double Vision	Yes, No
Headaches	Yes, No	Itching	Yes, No	Floaters or Spots	Yes, No
Glare/Light Sensitivity	Yes, No	Mucus Discharge	Yes, No	Flactuating Vision	Yes, No
Tired Eyes	Yes, No	Drooping Eyelid	Yes, No	Loss of Vision	Yes, No
Amblyopia (Lazy Eye)	Yes, No	Redness	Yes, No	Loss of Side Vision	Yes, No
Burning	Yes, No	Sandy or Gritty Feeling	Yes, No

General Health Condition:

Fever	Yes, No	Respiratory (Asthma)	Yes, No	Anxiety or Depression	Yes, No
Weight Loss	Yes, No	Gastrointestinal	Yes, No	Thyroid, Diabetes	Yes, No
Other Symptoms	Yes, No	Kidney	Yes, No	Blood/ Lymph	Yes, No
Ears, Nose, Throat	Yes, No	Muscles, Bones, Joints	Yes, No	Allergic	Yes, No
Cardiovascular	Yes, No	Skin	Yes, No	Are you pregnant?	Yes, No
		Neurological (Multiple Sclerosis)	Yes, No	Are you nursing?	Yes, No

Family History:

Amplyopia (Lazy Eye)	Yes, No	Relationship to Patient	Systemic Diseases		Relationship to Patient
Blindness	Yes, No		High Blood Pressure	Yes, No
Cataract(s)	Yes, No		Kidney Disease	Yes, No
Color Blindness	Yes, No		Lupus	Yes, No
Glaucoma	Yes, No		Stroke	Yes, No
Macular Degeneration	Yes, No		Thyroid Disease	Yes, No
Retinal Detachment	Yes, No		Other	Yes, No
Strabismus (Eye Turn)	Yes, No			Yes, No

Social History:

Current Ocupation: _____________________ Years _____ Employer ____________________

School _____________________________ Grade _____

Spectacle Lens History:

Do you drive?	Yes, No
Do you havea glare problems?	Yes, No
Do you have visual difficulty when driving?	Yes, No
Do you have problems with night vision?	Yes, No
Do you currently wear glasses?	Yes, No
Type of glasses:	Fulltime, Parttime, Distance, Readers
Glasses Owned:	Single Vision, Bifocals, Trifocals, Backup, Safety, Progressive
Have you had trouble in the past with glasses?	Yes, No
Do you wear sunglasses?	Yes, No
Are they prescription sunglasses?	Yes, No
Do you currently wear contact lenses?	Yes, No
Type of contact lenses:	Single Vision, Mono Vision, Bifocals
Name of the contact lesnes (Brand):
Name of the contact lens solution:
How often do you replace the lenses?	2wks, 3wks, 4wks, 5wks, 6wks, 7 wks, 2months

Social History:

Do you take supplements (vitamins, etc.)	Yes, No
Do you drink alcohol? If yes, how much/ often?	Yes, No, Occasional, 1 per day, 2 per day, more
Do you smoke?	Yes, No
Do you use illegal drugs?	Yes, No
Hobbies / Interests?