Appointment Request Form

Name *

First

Last

Date of Birth *

Sex *

Phone *

Email *

Address *

First

Last

Has anyone in your immediate family been diagnosed with:

Have you been diagnosed with:

Cardiovascular

Heart Diease
High Blood Pressure

Respiratory

Asthma
Emphysema

Gastrointestinal

Stomach Issues
Ulcer
Acid Reflux (GERD)

Endocrine

Diabetes
Thyroid Dysfunction
High Cholesterol

Blood/Lymph

Anemia
HIV

Allergic/Immunologic

Lupus
Seasonal/Hay Fever

Genitourinary

Kidney
Bladder
Prostate

Skin

Acne
Skin Cancer

Psychiatric

Anxiety
Depression

Neurological

Multiple Sclerosis
Headaches

Muscles, Bones, Joints

Rheumatoid Arthritis
Psoriasis
Osteoporosis

Other (Please Fill In)

Please check the applicable circle that best describes your choice: *

Eye Exam ONLY
Eye Exam and Glasses ONLY if there is a change in prescription
Eye Exam and Glasses even if there is no change in prescription
Glasses ONLY (I have already had an eye exam this year)

Consent for Treatment *

By filling out this form, I consent to an eye exam with Bridge Hill for myself or my dependent, including any procedures legally defined as the Practice of Optometry in Missouri, and give consent for a dilated eye exam, if the doctor deems it necessary. I also authorize the release of information to another doctor or other qualified person, if necessary for my care.

The law requires that Bridge Hill make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that (Please check one of the following): *

I have read or had explained to me Bridge Hill’s Notice of Privacy Practice and agree to continue my care with Bridge Hill under said terms.
I was given the opportunity to read Bridge Hill’s Notice of Privacy Practices and declined, but wish to continue my care with Bridge Hill under the terms of Bridge Hill’s privacy policies.
I have read or had explained to me Bridge Hill’s Notice of Privacy Practice and do not wish to continue my care with Bridge Hill under said terms.

Additionally, I authorize Bridge Hill to grant access to health information identifying me (including, if applicable, information about substance abuse, mental health conditions, and HIV infection or AIDS) to the following individuals (This may include parents, step parents, grandparents and any care takers who can have access to this patient’s records):

First

Last

First

Last

First

Last

First

Last

It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices. When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes. I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. *

First

Last

If you are signing as a personal representative of the patient, please indicate your relationship

First

Last

The eye care profession is unique and different from almost any other health profession, in that we utilize two different types of coverage; vision care plans and health insurance plans, where each covers vastly different types of eye exams, procedures and products. To help you understand, here is a brief explanation. During your visit, if the doctor determines that you have entered the office for a medical reason, presenting problem, symptom, or complaint, the care that is provided is considered medical and will be appropriately billed to your health insurer and/or to you. If the doctor determines that you have entered the office for a routine exam without any medical problems or symptoms present your exam will be billed to your vision care plan and/or to you. In order to see our patients in a timely manner and to do business efficiently at Bridge Hill, we ask that you read over the following Financial and Office Policies as they relate to your care here. Thank you! Please check each box after you have read it. *

PAYMENTS: I will promptly pay all amounts that have been determined my responsibility by my insurance carrier. I understand that my vision plan coverage and/or health insurance copays, coinsurance and deductibles are between my insurance company and myself, and that Bridge Hill only enforces those agreements. I also understand that if I do not have any insurance coverage any services rendered are my personal responsibility, and that full payment is due at the time of service. Any balance remaining after my health insurance pays, denies or deems non-covered under my plan will be my responsibility. If my insurance company does not pay for services rendered by Bridge Hill within 45 days, I will be responsible for those charges and will make immediate payment.
CHECK-IN/CHECK-OUT: Bring your current insurance card(s) with you at each visit. We will ask you to verify insurance and demographic information so that our records remain current. If you do not have your copay or are not prepared to pay past due balances, your appointment may be rescheduled for a later time when you are able to meet your payment obligation. Co-pays, charges for services rendered not covered by your insurance company, and past due amounts are due at the time you check out.
SERVICE FEES: Your account will be charged $25 for insufficient funds or returned checks. Bridge Hill may ask for assistance from an outside collection agency if you fail to pay or make arrangements for payment. If your account is turned over to a collection agency, a non-reversible service fee of $40 will be assessed and you will be dismissed from the practice. We will make every effort to avoid this action.

I have read, understand and agree to the above financial and office policies. *

First

Last

Patient Electronic Signature (or Responsible Party) *

Appointment Request Form

Has anyone in your immediate family been diagnosed with:

Have you been diagnosed with:

Share this:

Like this: