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Preferred (if different):
How did you learn about Joffe MediCenter?
If referred by a previous patient, who was it?
Were you referred to Joffe MediCenter by your eye doctor? Yes No
Will you use funds from your flexible spending account to help pay for this procedure?
Did you shop other laser vision correction providers?
How long have you been considering laser vision correction?
Is your current eyeglass or contact lens prescription about to expire?
DO YOU HAVE OR HAVE YOU EVER BEEN TREATED FOR THE FOLLOWING:
Collagen, vascular, autoimmune, or immunodeficiency disease (e.g., Arthritis, Lupus or HIV)?
Show signs of keratoconus (a corneal disease) or have any other condition that causes thinning of your cornea?
Taking Accutane (isotretinoin) for acne treatment or Cordarone (amiodarone hydrochloride) for controlling normal heart
IN CASE OF EMERGENCY
RELEASE OF INFORMATION / OTHER
I understand that this evaluation is for laser vision correction purposes only. There would be a $100 release of records charge if I wish a copy of my results to be released to myself or another facility. I further understand that Joffe MediCenter may record my preoperative examination for internal training purposes.
ABOUT YOUR VISION
Who is your current eye doctor/optometrist?
Do you currently have trouble with bright lights?
Do you currently have trouble with night vision?
Do your glasses have prisms in them to help with double vision?
Soft Toric Hard Rigid gas permeable Disposable Daily Wear Extended Wear (sleep in)
Have you ever had a corneal abrasion or erosion?
Have you ever had any surgery, injuries or laser treatments to the eye?
Please list any eye drops you are presently using
: Is there a family history (parents and/or siblings only) of:
Cataracts Glaucoma Strabismus (lazy eye) Retinal disease Diabetes Blindness
Do you have or have you ever been treated for the following:
If yes, how long?
Are you ALLERGIC
to any medications? (Please List) Yes No
Are you CURRENTLY TAKING
any medications - including over-the-counter, vitamins, supplements, or recreational? (Please List) Yes No
Have you had any previous surgeries? Yes No
CLIENT: ACCOUNT #. .
HIPAA Information and Consent Form
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. This form is a friendly version. Please let us know if you would like additional information. What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPPA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality, professional service and care. Additional information is available from the U.S. Department of Health and Human Services at www.hhs.gov. We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all
administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, and health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front desk, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, email, U.S.
mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
3. Joffe MediCenter utilizes a number of vendors in the conduct of business. These vendors may have access to PHI,
but must agree to abide by the confidentiality rules of HIPPA.
4. You understand and agree to inspections of the office and review of documents which may include PHI by
government agencies or insurance payers in normal performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention of our HIPPA compliance officer
6. Your confidential information will not be used for the purposes of third-party marketing or advertising of products,
7. We agree to provide patients with access to their records in accordance with state and federal laws.
8. We may change, add, delete or modify any of these provisions to better serve the needs of both Joffe MediCenter
9. You have the right to request restrictions in the use of your protected health information and to request change in
certain policies used within the office concerning you PHI. However, we are not obligated to alter internal policies to conform to your request.
I, ________________________________________________________, do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward. Signature___________________________________________________ Date__________________________
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