Please enable JavaScript in your browser to complete this form.Personal Information - Step 1 of 6Resident's Name *FirstLastDate of Birth *Sex *MaleFemaleNursing Home or Facility *Addington Place of Lee's SummitAddington Place of Shoal CreekAnthology at Burlington CreekBenton House of Blue SpringsBenton House of RaymoreBenton House of Staley HillsBenton House of Tiffany SpringsBickford of RaytownDelaware Highlands Assisted LivingJohn Knox VillageKingswood Senior Living CommunityLamar Court Assisted Living CommunityMcCrite Plaza at BriarcliffNew Mark Care CenterPrimrose Retirement CommunitySanta Marta Retirement CommunitySilvercrest at Deer CreekSummitView TerraceThe Gardens at Barry RoadThe Oxford GrandIf you do not see your loved ones' nursing home on this list, please visit the "Contact Us" page and send us a note. NextResponsible Party NameFirstLastAddress *FirstLastEmail *Phone *PreviousNext - Family Medical HistoryHas anyone in your immediate family been diagnosed with:Family Ocular Health History *CataractsCrossed Eyes (Strabismus)GlaucomaMacular DegenerationRetinal DetachmentRetinal DiseaseNo Known DiseasesUnknownFamily Health History *CancerDiabetesHigh Blood PressureHigh CholesterolThyroid DysfunctionNo Known DiseasesUnknownPreviousNext - Personal Medical HistoryHas the resident been diagnosed with:OcularGlassesCataractsGlaucomaMacular DegenerationOther Ocular Diseases (Please Fill In)PreviousNext - Consent for TreatmentPlease 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 examinationUpdated pair of glassesUpdated pair of glasses ONLY if there is a change in prescriptionConsent 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 policiesPreviousNext - Acknowledge of Notice of Privacy PracticesThe 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):FirstLastFirstLastFirstLastFirstLastIt 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. *FirstLastIf you are signing as a personal representative of the patient, please indicate your relationship FirstLastPreviousNameSubmit Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window)Click to share on Pinterest (Opens in new window)Click to email a link to a friend (Opens in new window)MoreClick to share on LinkedIn (Opens in new window)Click to share on Reddit (Opens in new window)Click to share on Tumblr (Opens in new window)Click to share on Pocket (Opens in new window)Click to share on Telegram (Opens in new window)Click to share on WhatsApp (Opens in new window)Like this:Like Loading...