New Patient Form

Thank you for choosing Clarity Eye Care, PLC for your eye care needs. We are committed to providing you with the highest quality vision care in a timely and cost effective manner. Please take a moment to answer the questions below.

Full Name: _____________________________________________ Birth date: _________________________

When was your last eye exam? ___________Where was your last eye exam ? ___________________________

How did you hear about us? [ ] Newspaper [ ] Internet/Web Page [ ] Facebook [ ] Family/Friend

[ ] Other___________________________________________________________

We like to thank those who have referred you to our office. Please list the name of that person below:

Name of referrer : __________________________________________________________________________

IF YOU HAVE COMPLETED YOUR REGISTRATION THROUGH OUR PATIENT REGISTRATION PORTAL YOU MAY STOP HERE. OUR PORTAL CAN BE FOUND AT https://compulinkadvantageweb.com/register/accountappts/index/7024

Full Legal Name : _____________________________________ Preferred Name: _______________

Date of Birth: ______________________________ last 4 digits of social security # ______________

Address: ___________________________________ Home Phone _____________________________

___________________________________________ Cell Phone ______________________________

Employer: ___________________________________ Work Phone ____________________________

Occupation _________________________________________________________________________

Primary Care Doctor ____________________________ Last Medical Exam _____________________

Medical Insurance and Policy Number ___________________________________________________

Vision Insurance: [ ] VSP [ ] Eyemed [ ] Other ____________________________________________

Electronic Communication:

In an effort to be in compliance with recent government regulations, we are asking that you share your email address with us. We will be using this address to give you electronic access to information related to your exam including the ability to view diagnosis and plan information obtained during your examination.

There may also be a limited number of emails regarding appointments, recalls, or other incidental information. If you would prefer to not receive those additional emails and only receive a link for medical chart access please check and initial here [ ] ________.

Email address _______________________________________________________________________

Clarity Eye Care No Show Policy

Each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. In addition, if there is a 20% no show rate, we must in turn “overbook” by 20%. As a result, the waiting area becomes crowded and waiting times as well as stress levels increase. Therefore, Clarity Eye Care reserves the right to charge a fee of $40 for all missed appointments ( “no shows” ) and appointments which, absent a compelling reason, are not cancelled with at least a 24 hour advance notice.

The CMS (Center for Medicare Services) authorizes physicians and suppliers to charge a missed appointment fee to Medicare patients provided that they also charge non-Medicare patients the same fee. Therefore, “No Show” fees will be directly billed to you (the patient). This fee is not covered by insurance and must be paid prior to your next appointment. Multiple “no shows” in any 12 month period may result in termination from our practice.

I have read and understand the above policy (sign/date) _____________________________________________

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HIPAA Privacy

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I ______________________________________________ [Please print full legal name] (the “Patient” or “Patient's legal representative) have been presented with the Notice of Privacy Policy (the “Policy”) of Clarity Eye Care (the “provider”), and have been offered a copy of such policy to keep for my records.

_______(please initial here) I hereby acknowledge that I have been provided with a copy of the policy

_______(please initial here) I hereby refuse to acknowledge receipt of the Policy. I understand that even through I may refuse to sign this acknowledgement, Provider may still provide treatment for me

Signature/Date ______________________________________________________________________

OFFICE USE ONLY

I ________________________ acting as ______________________ (please print relationship to or official position with Provider) for Provider attempted to obtain the written acknowledgment of receipt of the policy of Provider on ___________ (insert date attempt was made), but acknowledgment could not be obtained because

_________ (intial here) Patient or Patient's legal representative refused to sign

_________ (initial here) Patient or Patient's legal representative could not be communicated with sufficient to obtain acknowledgment

______(initial here) Emergency circumstances prevented securing acknowledgment

______ (initial here) Other (please specify) : _____________________________________________