Patient Registration Forms

Patient Information

Personal Information - 1 of 3 PDF

Patient Information

Patient's Employer Information
Accident Information N/A
(Complete this if you are being treated due to an accidental injury.)

Were you referred to us by a:

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What Newspaper?

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Responsible (Or Insured) Party Information Self

Insurance Information N/A

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HEALTH HISTORY - 2 of 3 PDF
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YOUR OCULAR HISTORY (Have you been diagnosed with any of the following in the past?)

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Family History (Has anyone in your family (blood relative) had any of the following? )

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SURGICAL HISTORY

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Terms and Conditions - 3 of 3 PDF
INSURANCE POLICY:

Insurance provides for your reimbursement on allowed medical charges. As a courtesy to you, we will provide an itemized statement that you may send to your insurance company for payment. We will be happy to submit to most insurance carriers if you have provided us with policy numbers, address, place of employment and any other pertinent information. You are responsible for all deductibles and charges not covered by insurance. Please understand that we cannot, as a third party, become involved in prolonged insurance negotiations: this is your responsibility.

I authorize the release of any medical information necessary to process any claim. I permit a copy of the authorization to be used in place of the original. This authorization may be revoked by either me or my insurance company at any time in writing.

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS:

I authorize the Doctor to release any medical information including diagnosis, x-rays, test results, reports and records pertaining to any treatment or examination rendered to me. I understand that this medical information may be used for any of the following procedures: diagnostic, insurance, legal, scientific research, publications, presentations, and at times when the Doctor deems it necessary in order to ensure the best medical care on my behalf. I further understand that any person(s) that receive these medical records will not release any of the medical information obtained by this authorization to any person or organization without further authorization signed by me for release of the information.

TERMS AND CONDITIONS

Customer agrees to pay a finance charge of one and one-half percent (1 ½%) per month on all amounts due and owing to Hoopes Vision Correction Center, EyeSurg of Utah or Laser and Refractive Surgery Center of Utah.

ATTORNEY’S FEES AND COSTS:

If any legal action is necessary to enforce the terms of this Agreement, or if it is necessary to employ the services of an attorney to enforce the terms of this Agreement, the party in default or in breach hereof agrees to pay the other party’s reasonable attorney’s fees and court costs in addition to any other relief to which it may be entitled if Customer fails to pay any amounts owing hereunder when due, or otherwise breaches any terms of this Agreement. Customer agrees to pay up to a 40% collection expense incurred by Hoopes Vision Correction Center in attempting to collect such amounts from Customer, in addition to the aforementioned attorney’s fees and cost

IN CASE OF EMERGENCY PLEASE CONTACT:
NOTICE OF PRIVACY PRACTICES

I, acknowledge that I have received a copy of Hoopes Vision Correction Center “Notice of Privacy Practices”. This Notice describes how Hoopes Vision Correction Center may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.