Patient Registration Forms First Name* Last Name* Middle Initial Preferred Name Birth Date* Social Security Number* Insured's Name* Sex Male Female Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Which phone number would you prefer we use to contact you?* Home Work Cell Home PhoneWork PhoneCell Phone*Email address* Marital Status Single Married Referred By We must have a copy of all insurance cards on the day of service.Primary Medical Insurance* Secondary Medical Insurance Vision Insurance Insured Social Security Number* Insured's Birth Date* Insured's Employer Family Doctor Family Dr. Clinic/Phone Family Members For ease of data transfer, are they patients at this office?* Yes No NOTICE OF PRIVACY PRACTICES: I/We have been offered a copy of Simple Optical, Inc. d/b/a Gunbarrel Optometry statement on privacy practices AUTHORIZATION TO RELEASE INFORMATION: I/We hereby authorize Simple Optical, Inc. to release any medical or incidental information that may be necessary for medical benefit of in processing applications for financial benefit. This includes but is not limited to my insurance company, Rehabilitation Services, Social Security Administration, and Worker’s Compensation. CONSENT FOR TREATMENT: I/We hereby authorize Simple Optical, Inc. to administer diagnostic and medical procedures as may be necessary for proper health care. OFFICE POLICY ON PAYMENT: I understand that I am responsible for payment of all charges. As a courtesy, my insurance will be billed for me. It is my responsibility to pay any deductible, copay or any other balance not paid by my insurance company. I authorize insurance benefits to be paid directly to the provider. VISION PLAN COVERAGE: I/We understand that only one vision plan may be used for exam/materials per visit-per patient and that the vision plan to be used must be chosen before the exam occurs and can not change at a later date. Due to changes in insurance regulations, if you have both a vision plan and a medical insurance plan, we are now required to coordinate your benefits with both plans. If you are being seen for a medical problem, or if you have any medical conditions that can affect the eyes or vision, your medical insurance will be billed first. Some of these medical conditions include: macular degeneration, diabetes, high blood pressure, blurred vision, glaucoma, flashes, floaters, rosacea, eye pain, itchy eyes, Bell’s Palsy, double vision, allergies, foreign body, eye trauma, corneal ulcers, eye injury, swollen eyelids, headaches, chalazion, dry eye, red eyes, stye, drooping eyelids, “pink eye”, burning eyes, shingles, etc. If you are here for a comprehensive, or annual, exam, we must now submit the eyeglass prescription determination portion of the visit to your vision plan after submitting any medical claim to your medical insurance plan. You may still use vision plan materials benefits, if eligible, at the time of your exam. Signature*Date* MM slash DD slash YYYY CHIEF COMPLAINTHow can we help you today? In this space please check/explain any signs and/or symptoms you are experiencing. Medical insurance will only cover if there is a medical reason for the exam/test such as loss of vision, headaches, eye pain, eye itching or burning, redness, glaucoma, cataracts, floaters, dry eyes, Due to changes in insurance regulations, if you have both a vision plan and a medical insurance plan, we are now required to coordinate your benefits with both plans. If you are being seen for a medical problem, or if you have any medical conditions that can affect the eyes or vision, your medical insurance will be billed first. Some of these medical conditions include: macular degeneration, diabetes, high blood pressure, blurred vision, glaucoma, flashes, floaters, rosacea, eye pain, itchy eyes, Bell’s Palsy, double vision, allergies, foreign body, eye trauma, corneal ulcers, eye injury, swollen eyelids, headaches, chalazion, dry eye, red eyes, stye, drooping eyelids, “pink eye”, burning eyes, shingles, etc. If you are here for a comprehensive, or annual, exam, we must now submit the eyeglass prescription determination portion of the visit to your vision plan after submitting any medical claim to your medical insurance plan. You may still use vision plan materials benefits, if eligible, at the time of your exam. etc.Select all that apply Loss of vision Blurred vision Double vision Floaters Crossed eyes Flashes of light Eye pain/soreness Watery Eyes Sandy/gritty feeling Glare Light sensitivity Tired eyes Dry eyes Red eyes Burning/itching HISTORY OF PRESENT ILLNESSLocationWhich eye has the problem? Right Left Both TimingIs it new, ongoing, returning? New Ongoing Returning QualityHow is it effecting you? Bothersome Aware Painful ContextAssociated w/ Infection Medical condition Injury Surgery SeverityHow severe is the problem? Mild Modern Severe ModifiersPrevious treatment? Drops Medication Other Please describe How long have you had the problem? SymptomsAre there associated symptoms? Headache Other Please describe FAMILY HISTORYHas anyone in your family been diagnosed with any of the following (check all that apply) No Problems Amblyopia Diabetes Cataracts High blood pressure Macular degeneration Cancer Glaucoma Strabismus (eye turn) SOCIAL HISTORYDo you smoke?* Yes No What do you smoke?* How much per month do you smoke?* Do you consume alcohol?* Yes No How much do you drink?* What is your occupation?* CURRENT VISIONDo you currently wear glasses?* Yes No What type of lenses are in your glasses?* Single Vision Bifocal Trifocal No-Line (Progressive) Do you currently wear contact lenses?* Yes No What type of contact lenses do you wear?* Soft Rigid What is the manufacturer/model of your contact lenses?* What are the powers of your contact lenses (if you know)? How old are your current contact lenses? Weeks/Month/YearsHow often do you replace your contact lenses?* Daily Weekly 2 weeks Monthly 3 months 6 months Annually What solutions do you use to care for contact lenses?* Renu Optifree Clear Care Boston Advance Boston Simplicity Optimum Other Please list* REVIEW OF SYSTEMSOcular/Eye ProblemsCheck all that apply. Inflammatory disorder Surgery Glaucoma Amblyopia (lazy eye) Cataract Retinal problems Macular degeneration Strabismus (eye turn) Patching Other Constitutional ProblemsCheck all that apply. Cancer Fatigue Developmental disability Other Ears, Nose, Mouth, Throat ProblemsCheck all that apply. Laryngitis Dry mouth Hearing loss Sinusitis Other Neurological ProblemsCheck all that apply. Cerebral palsy Multiple sclerosis Tumor Epilepsy Other Psychiatric ProblemsCheck all that apply. Depression Other Cardiovascular ProblemsCheck all that apply. Vascular disease Stroke Congestive heart failure Heart disease High blood pressure Other Respiratory ProblemsCheck all that apply. Emphysema Bronchitis Smoker COPD Asthma Other Gastrointestinal ProblemsCheck all that apply. Colitis Chron’s disease Ulcer Other Genitourinary ProblemsCheck all that apply. Prostate disease/cancer STD Kidney disease Other Musculoskelatal ProblemsCheck all that apply. Ankylosis spondylitis Fibromyalgia Muscular dystrophy Osteoarthritis Other Skin ProblemsCheck all that apply. Rosacea Psoriasis Eczema Other Endocrine ProblemsCheck all that apply. Insulin dependent diabetes Hormonal dysfunction Thyroid dysfunction Non-insulin diabetes Other Blood/Lymph ProblemsCheck all that apply. Large volume blood loss Anemia Other Allergy/Immunologic ProblemsCheck all that apply. Environmental allergies Rheumatoid artheritis Drug allergies Lupus Other If you answered "other" to any of the above questions, please describe.Do you sometimes experience dry eyes?* Yes No Are your eyes sensitive to sunlight?* Yes No Do you work at a computer?* Yes No Problems with reflections and/or glare?* Yes No Prefer not to wear your glasses at times?* Yes No Interested in newer contact lens technology?* Yes No Want information on thinner/lighter lenses?* Yes No Want information on LASIK vision surgery?* Yes No Want a non-surgical option to LASIK?* Yes No Do you have any children?* Yes No Do you spend time outdoors?* Yes No Please list your sporting activities/hobbies:List any medications you are currently taking:List any medicine allergies:List any other allergies:REGARDING VISION PLAN & MEDICAL INSURANCEWe often have patients that have both a vision plan (for example, VSP or EyeMed) and a medical insurance (for example, Cigna, Anthem, Humana, Aetna, United Healthcare, or Medicare). They are very different in terms of the services they cover, and it's important for our patients to understand these differences. A vision plan is designed mainly to cover determining a prescription for glasses and contact lenses, to help pay for glasses or contact lenses, and to cover a yearly wellness evaluation of the health of the eyes in a healthy patient that has no particular problems or symptoms. Vision plans are not equipped to deal with and do not cover medical conditions, injuries, and/or treatments. Medical insurance is designed to cover you when you have a medical problem, including one that affects your eyes. Medical insurance does not cover routine services or examinations for glasses, or routine vision problems such as nearsightedness, farsightedness, and astigmatism. Those are only covered by your vision insurance. When a medical diagnosis or medical condition is present that affects your eyes, such as high blood pressure, high cholesterol, or diabetes, to name just a few examples, or you have an eye disease or eye problem such as macular degeneration, an infection (pink eye), dry eyes, allergy, or cataracts, again, just to name a few, we must file the claim with your medical insurance, and the co-pays and deductibles for that insurance will apply. Your vision plan does not cover these kinds of problems. Our office does not make these rules, they are made by the insurance companies themselves, and we must comply with them. There is often no way to know prior to your examination which type of insurance will be the right one to file your claim with. We make every effort to join as many insurance panels, both medical and vision, as we can for your convenience. If we are on your insurance company's panel we will file those claims for you. In the event that we do not accept your medical or vision insurance we will provide you with an itemized receipt so that you may file a claim for reimbursement with your insurance company yourself. If you have any questions, please let us know. I understand the information I've just read about the difference between vision and medical insurance. I authorize Philip Wren, O.D. to file my claim with the appropriate insurance based on the reason for my visit and the results of my examination.Signature*Date* MM slash DD slash YYYY CONTACT LENS POLICYIf your appointment includes a contact lens fitting and evaluation, the following policy applies. I understand that contact lenses are medical devices and state law prohibits dispensing contacts after one year from the date of the examination. Disposable trial lenses are for fitting purposes only and will be dispensed at the initial fitting exam only. I understand that I should have a pair of glasses as a back-up to contact lenses. Contact lens prescriptions will be released to the patient after an assessment has been made by the doctor to deem an appropriate fit. I understand that not all contact lenses are designed for overnight wear and if I am fit with extended wear lenses, that I will follow the maximum extended wear recommendation. Contact lens examination fees, as with all other professional fees, are non- refundable. Contact lens examinations include follow-up visits for 60 days after the initial fitting exam. It is the patient’s responsibility to make sure that the follow-up is completed within the 60 day time period. If you fail to keep scheduled follow-up visits as recommended by the doctor during the 60 day period, additional office visit charges will apply. Any issues concerning the purchase or fees of the actual contact lenses are to be directed to the location where the contact lenses are purchased. Any medical eye conditions arising from contact lens wear will be billed as an office visit.Signature of patient (or parent if a minor)*Date* MM slash DD slash YYYY NOTICE OF PRIVACY PRACTICESEffective date of notice: 04/01/2015 Simple Optical, Inc. dba Gunbarrel Optometry 6545 Gunpark Dr., Ste. 250 Boulder, CO 80301 303-530-1973 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records. We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission. USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are: When a state or federal law mandates that certain health information be reported for a specific purpose; For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices; Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws; Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies; Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; Uses or disclosures for health related research: Uses and disclosures to prevent a serious threat to health or safety; Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service; Disclosures of de-identified information; Disclosures relating to worker’s compensation programs; Disclosures of a “limited data set”for research, public health, or health care operations; Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; Disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information; [Specify other uses and disclosures affected by state law]. Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your eye care. APPOINTMENT REMINDERS We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home. OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You can: Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. Ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address or fax shown at the beginning of this Notice. Get a list of the disclosures that we have made of your health information within the past six years (or shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address or fax shown at the beginning of this Notice. OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site. COMPLAINTS If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone. FOR MORE INFORMATION If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICESThe law requires that Simple Optical, Inc., d.b.a. Gunbarrel Optometry make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:* I have read or had explained to me Gunbarrel Optometry’s Notice of Privacy Practice and agree to continue my care with Gunbarrel Optometry under said terms. I was given to opportunity to read Gunbarrel Optometry’s Notice of Privacy Practices and declined but wish to continue my care with Gunbarrel Optometry under the terms of Gunbarrel Optometry’s privacy policies. I have read or had explained to me Gunbarrel Optometry’s Notice of Privacy Practice and do not wish to continue my care with Gunbarrel Optometry under said terms. The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described as... Please describe* I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.Patient Signature*Date* MM slash DD slash YYYY If you are signing as a personal representative of the patient, please indicate your relationship:Representative Relationship to Patient CommentsThis field is for validation purposes and should be left unchanged.