New Patient Intake Forms

Please submit both forms, not just the bottom.

PATIENT DETAILS

Please tick all that apply

EMERGENCY CONTACT INFORMATION/ Responsible Party (Under 18)

INSURANCE PROVIDER

Signature Pages

The law requires the Corinth Eye Clinic, Inc/Weeden Eye Clinic make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that: I have been given the opportunity to read, have read , or had explained to me prior to any services offer Corinth Eye Clinic, Inc's Notice of Privacy Practice and agree to continue my care with Corinth Eye Clinic under said terms. By submitting this form I authorize the release of information about my health and/or appointments to the following people who are not my doctors or insurance providers. This digital signature is also my authorization for the release of information to process my insurance claim. I hereby authorize payment to this doctor of office named of the benefits otherwise payable to me. This signature may be used for all insurance claims unless revoked in writing.

Cancellation and No Show Policy

At Corinth Eye Clinic/ Weeden Eye Clinic our goal is to provide quality care in a timely manner. No shows and late cancellations inconvenience those individuals who need access to timely medical care. This policy enables us to better utilize available appointments for our patients in need of eye care. A cancelation is considered late when a patient contacts us to cancel their appointment less than 24 hours in advance. A no show is determined when a scheduled patients misses their appointment without contacting us. A failure to be present at the time of your appointment without a call to cancel the appointment will be recorded in your record as a no show.

No Show/Cancellation Fee

If a patient no shows or fails to provide a 24 hour notice, they will be subject to a $25 scheduling fee which will be collected up front prior to next appointment. The Cancellation and no show fees are the sole responsibility of the patient and must be paid in full before the patients next appointment.

We understand that special unavoidable cirucmstances may cause you to cancel within 24 hours, in such instances the fee with be waived upon management approval.

We make every effort to keep down the cost of your medical care. You can help by paying in full upon the completion of each visit. If you have any vision and/or medical insurance we will be glad to fill out the proper forms or file the claim for you, but please complete the identifying information within this paperwork. If you are using insurance coverage for today's visit--this is a contract between you and your insurance company, not Weeden Eye Clinic, Inc., or Dr. Michael Weeden. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures or items and others pay a percentage of the charge. It is your responsibility to know the terms and limitations of your policies. For patients with BOTH medical and Vision coverage, your vision insurance is intended to provide you with a baseline eye exam. If you are being evaluated for medical reasons (corneal disorders, diabetes, cataracts, glaucoma suspect, double vision, etc.), you are being provided with medical care. Typically your vision company does not provide coverage for medical care. Therefore, we will file a claim with your medical insurance for visits related to medical complaints and problems. I certify that the insurance information that is on this form or provided to this office is accurate. I understand I am financially liable for any deductible amount, co-insurance & non-covered services or any other balance not paid by my insurance company(s). I understand that you may bill me if my insurance company takes longer than 90 days to pay your office. If my insurance company denies payment, I agree to be personally responsible for payment. If I have no insurance, I understand that I am responsible for the entire balance of services and products provided. I will be responsible for all collection costs, attorney’s fees, and court costs should my account be turned over to collection. I certify that I understand there are no refunds or exchanges and that all sales are final unless covered under manufacturer or office warranty programs.
http://weedeneyeclinic.com/new-patient-center/payment-options/

THIS DIGITAL SIGNATURE WILL ALSO SERVE AS A PROTECTED HEALTH INFORMATION DOCUMENT RELEASE SHOULD I REQUEST MY MEDICAL RECORDS BE SENT TO/FROM ANOTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

FINAL STEPS

Please submit the above form before moving on....

Medical History Questionnaire

Family History

Please note any immediate family history (Parents, Siblings, Children...living or deceased) All not marked will be considered no.

Social History

IPAD, Phone, Tablet, Computer

Your Medical History