Appointment Request Form Nursing Homes

Resident's Name *

First

Last

Date of Birth *

Sex *

Nursing Home or Facility *

If you do not see your loved ones' nursing home on this list, please visit the "Contact Us" page and send us a note.

Responsible Party Name

First

Last

Address *

First

Last

Email *

Phone *

Has anyone in your immediate family been diagnosed with:

Family Ocular Health History *

Cataracts
Crossed Eyes (Strabismus)
Glaucoma
Macular Degeneration
Retinal Detachment
Retinal Disease
No Known Diseases
Unknown

Family Health History *

Cancer
Diabetes
High Blood Pressure
High Cholesterol
Thyroid Dysfunction
No Known Diseases
Unknown

Has the resident been diagnosed with:

Ocular

Glasses
Cataracts
Glaucoma
Macular Degeneration

Other Ocular Diseases (Please Fill In)

Please read the following financial and office policies. Once you have read them, please check the corresponding box. *

All exam service fees will be submitted to your health insurance. You are subject to the insurances copays, co-insurances, and deductible, if not met. If you have a copay, expect to pay the “Specialist” copay. This is typically found on your insurance card.
The refraction (finding the glasses prescription) will be submitted to your insurance but this service is sometimes not covered. The refraction is a $30 fee.
Examinations are performed yearly and may be sooner, based on the exam findings.
A complete pair of glasses which include, frame, lenses, and a one-year, one-time warranty are priced at: $99 for single vision, $149 for lined bifocals, $199 for lined trifocals, and $199 for no-line bifocals.
Add-ons, such as anti-reflective treatment ($50) and transitions ($75) will only be applied if their current glasses have them.
Service Fees: Your account will be charged $25 for insufficient funds for returned checks.

I would like (check all that applies) *

Yearly eye examination
Updated pair of glasses
Updated pair of glasses ONLY if there is a change in prescription

Consent for Treatment *

By filling out this form, I consent to an eye exam at Bridge Hill Eye for myself or my dependent, including any procedures legally defined as the Practice of Optometry in Missouri and Kansas, and give consent for a dilated 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. I have also read, understand, and agree to the above financial and office policies

The law requires that Bridge Hill make every effort to inform you of your rights related to your personal health information (found at http://www.bridgehilleye.com/hipaa). 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

Appointment Request Form Nursing Homes

Has anyone in your immediate family been diagnosed with:

Has the resident been diagnosed with:

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