tillamookvision - Registration

800 Main Ave, Suite A Tillamook, OR 97141 Phone: 503-842-5568
Thank you for choosing our office! Please complete all pages of this form in ink. If you have any questions, please contact us. We’ll be happy to help you!
Name*

Last Name First Name Middle Initial
Preferred Name*
Date of Birth*
Sex*

MF
Street Address:*
City:*
State:*
Zip:*
Mailing Address
City:
State:
Zip:
E-mail Address:
example@example.com
Primary Phone:
Is this your Cell, Home, Work, or Message?
Secondary Phone:
Is this your Cell, Home, Work, or Message?
Note: we confirm all appointments via text or email.
Which is your preference?

TextEmail
Employer:
Occupation:
Emergency Contact Name:
Date of Birth
Relationship to you:
Phone:
If the patient is a child, please complete the next section:
Mother’s First Name
Mother’s Last Name
Date of Birth
Cell Phone
Work Phone
Employer
Occupation
Father’s First Name
Father’s Last Name
Date of Birth
Cell Phone
Work Phone
Employer
Occupation
Financial Account Guarantor

Last Name First Name Middle Initial
Guarantor’s Relationship to Patient
Guarantor’s Date of Birth
- I authorize my insurance company to pay the doctor all insurance benefits for services rendered.
- I authorize the use of this signature on all insurance submissions.
- I authorize the doctor to release all information necessary to secure the payment of benefits.
- If applicable, I authorize release of my child’s exam results to his/her school.
My signature below provides long term authorization until my written notice otherwise.
Patient Signature*

Clear
Date*

MonthDay Year
Date
-OR-
Patient Representative Signature

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Description of Representative's Authority
Date

MonthDay Year
Date

TILLAMOOK VISION CENTER FINANCIAL POLICY
We are pleased to discuss our fees with you at any time. Your clear understanding of the financial policy is important to our professional relationship. Please ask us if you have any questions about our fees, financial policy, or your responsibility.
- Full payment for examination fees is due at time of service.
- For patients without vision insurance a 50% deposit of the total materials fee is required when materials are ordered, and the balance is due when materials are picked up.
- We accept cash, checks, Visa, MasterCard, Discover, American Express, CareCredit, and debit cards.
If you have insurance, we will help you receive maximum benefits. We submit claims directly to most insurance companies. If we are billing insurance for you, you can expect to pay your co-payment at the time of service.

If your insurance company has not paid the full balance within 45 days, you will be expected to pay the remaining balance.

If you are covered by an insurance company that we don’t directly bill, you will need to submit the claim yourself. You can expect to pay for your fees in full at the time of service, and your insurer will reimburse you.

Insurance is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, etc., other than to supply factual information as necessary. You are responsible for the timely payment of your account.

We ask that you give 24 hours notice if you are unable to keep your appointment. Patients who fail to give 24 hours notice will be assessed a missed appointment fee.

A service charge of 1.5% or $1.00 minimum per month will be applied to unpaid accounts after 60 days from the date of service. A late charge will be assessed to delinquent accounts.

I have read and understand the financial policy. I understand that I am financially responsible for all charges whether or not paid by insurance.
Print Patient Name*
Patient Signature*

Clear
Date*

MonthDay Year
Date
-OR-
Patient Representative Signature

Clear
Description of Representative's Authority
Date

MonthDay Year
Date

Acknowledgment and Consent
I understand that Lee Johnson, O.D. of Tillamook Vision Center, TVC OD LLC (referred to below as "this Practice") will use and disclose health information about me.

I understand that my health information may include information both created and received by the practice, may be in the form of written or electronic records or spoken words, and may include information about my health history, health status, symptoms, examinations, test results, diagnoses, treatments, procedures, prescriptions, and similar types of health-related information.

I understand and agree that This Practice may use and disclose my health information in order to:
- make decisions about and plan for my care and treatment;
- refer to, consult with, coordinate among, and manage along with other health care providers for my care and treatment;
- determine my eligibility for health plan or insurance coverage, and submit bills, claims and other related information to insurance companies or others who may be responsible to pay for some or all of my health care;
- and perform various office, administrative and business functions that support my physician’s efforts to provide me with, arrange and be reimbursed for quality, cost-effective health care.
I also understand that I have the right to receive and review a written description of how This Practice will handle health information about me. This written description is known as a Notice of Privacy Practices and describes the uses and disclosures of health information made and the information practices followed by the employees, staff and other office personnel of This Practice, and my rights regarding my health information.

I understand that the Notice of Privacy Practices may be revised from time to time, and that I am entitled to receive a copy of any revised Notice of Privacy Practices. I also understand that a copy or a summary of the most current version of This Practice’s Notice of Privacy Practices in effect will be posted in waiting/reception area.

I understand that I have the right to ask that some or all of my health information not be used or disclosed in the manner described in the Notice of Privacy Practices, and I understand that This Practice is not required by law to agree to such requests.

By signing below, I agree that I have reviewed and understand the information above and that I have received a copy of the Notice of Privacy Practices.
By Patient*

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Date*

MonthDay Year
Date
-OR-
By Patient representative

Clear
Date

MonthDay Year
Date
Description of Representative’s Authority:

Note: In order to provide you with the best possible benefit, we need your medical
insurance information in addition to your vision insurance information.
Please bring your current insurance cards to your next appointment.

PRIMARY MEDICAL INSURANCE:
Insurance Company:
Member ID#:
Group#:
If subscriber is different from you (the patient), please enter the following information:
Subscriber Name:
Subscriber Date of Birth:
Subscriber Address:
Subscriber Phone:
Subscriber Employer:
SECONDARY MEDICAL INSURANCE
Insurance Company:
Member ID#:
Group#:
If subscriber is different from you (the patient), please enter the following information:
Subscriber Name:
Subscriber Date of Birth:
Subscriber Address:
Subscriber Phone:
Subscriber Employer:
VISION INSURANCE:
Insurance Company:
Member ID#:
Group#:
If subscriber is different from you (the patient), please enter the following information:
Subscriber Name:
Subscriber Date of Birth:
Last Four of Subscriber’s SSN (used to look up benefits):
Subscriber Address:
Subscriber Phone:
Subscriber Employer:

Patient Name:
Birth date:
Who is your Primary Doctor?
(the provider/PCP/general practitioner you have established care with to see for your general medical needs)
Which Pharmacy do you prefer?
Do you take any medications?

YesNo

Patient Medication List: Complete form or bring your pre-printed copy

	Medication	Used For	Prescribed By
1
2
3
4
5

*We know that insurance companies do not always process claims within the legal guidelines. When that happens, we will be happy to file a complaint to the insurance commissioner to get your benefits released. Please sign this letter in the event that claims are unpaid at the prompt payment date on your behalf. Please do not fill in any blanks – only your signature is required at this time. Thank you!*

To Whom It May Concern:
My provider filed the attached claim form with
on
It has not been paid or denied. It is my understanding that there are state prompt payment laws and/or guidelines that monitor commercial insurance carriers. The State Insurance Department regulates these law and/or guidelines. Tillamook Vision Center’s staff has advised me that they have attempted to resolve the claim on
At this time, reimbursement is still outstanding with little regard to my legitimate rights to have my claim processed within the legal guidelines.

Benefits were assigned to Lee Johnson, OD, and as of today’s date, payment has not been received. As a result, I am responsible for payment of this bill.
Please accept this letter as a formal written complaint against
Sincerely,
Patient signature*

Clear
Captcha
Should be Empty:

	Yes	No
Cataract
Macular Degeneration
Glaucoma
Diabetes
Diabetic Retinopathy
Dry Eye
Eye Infection / Inflammation
Floaters and/or Flashes of Light
Iritis or Uveitis
Retina Defects / Degeneration

	Y	N	P
Kidney Disease
Prostate Disease / Cancer
STD
Benign Prostate Hypertrophy
Pregnant
Nursing
Herpes
Chlamydia

	Y	N	P
Hearing Loss
Sinusitis
Dry Mouth
Laryngitis

	Y	N
Redness
Burning
Itching
Tearing
Discharge

	Y	N	P
Multiple Sclerosis
Epilepsy
Cerebral Palsy
Tumor
Migraine

	Y	N	P
Osteoarthritis
Fibromyalgia
Muscular Dystrophy
Ankylosing Spondylitis
Osteoporosis
Gout

	Y	N
Blurred Vision
Eyestrain
Eye Pain
Severe Sensitivity to Light
Headache
Poor Night Vision
Bothersome Night Glare
Double Vision
Total Loss of Vision

	Y	N	P
Eczema
Rosacea
Psoriasis
Herpes Simplex / Cold Sores
Herpes Zoster / Shingles

	Y	N	P
High Blood Pressure
Stroke / CVA
Heart Disease
Vascular Disease
Congestive Heart Failure

	Y	N	P
Type 2 Diabetes
Type 1 Diabetes
Thyroid Dysfunction
Hormonal Dysfunction

	Y	N	P
Depression
Attention Deficit
Anxiety Disorder
Bipolar Disorder

	Y	N	P
Asthma
Bronchitis
Emphysema
Chronic Obstruction
Sleep Apnea

	Y	N	P
Anemia
High Cholesterol

	Y	N	P
Crohn’s Disease
Colitis
Ulcer
Acid Reflux
Celiac Disease

800 Main Ave, Suite A Tillamook, OR 97141 Phone: 503-842-5568