New Patient Registration

ATTENTION: Please complete your online registration at least 24 hours prior to your appointment time. 
Midwest Eye Institute Patient Registration Form
* required field

Midwest Eye Institute Patient Registration Form



















Spouse/Partner/Emergency Contact Information










Patient or Parent/Legal Guardian





Responsible Party: if other than patient, please complete




Check here if address is same as patient:





Referring Physician and Pharmacy Information







Medical Insurance Information

Note: If Yes, we will take a copy of your insurance card(s) when you arrive for your appointment.


Accident Information



Medical History


Social History







Surgical History


Medications and Allergies



Family History


Review of Systems



Authorization

Release of Information:

I authorize the release of any medical information necessary to my insurance company relative to services rendered. I further authorize the Payment of Benefits to the Physician for services rendered. I understand that this authorization remains valid unless/until I revoke it myself.

Financial Responsibility statement:

I acknowledge responsibility for payment of all medical fees regardless of insurance I may have to assist me in this responsibility. The only exception will be charges for services covered under a contractual agreement that has been entered into between my physician and an insurance company, or other third party payer. If for any reason my account should become delinquent, I am liable to pay all collection and legal fees.



Imaging Release:

I consent that images, including photographs, may be taken in connection with the medical services I receive. I understand that such images shall be retained in my medical record and may need to be shared with others, including but not limited to my insurance carrier. I also give permission for these images and information relative to them and/or relating to my case to be published and republished for the purposes of medical research, education or science. I realize any publication of these images will be "de-identified" so they cannot be recognized as belonging to me specifically. I understand that this release remains valid unless/until I revoke it myself.


Dilation of Your Eyes

During the course of your exam, it may be necessary to dilate your eyes with drops. In some people, the dilating drops cause blurred vision, light sensitivity, and inability to read. These problems go away as the effects of the drops wear off. You should be careful walking, going up and down stairs, and should not drive a car. In very rare cases, the drops may cause elevated eye pressure requiring further treatment. It is for this reason that we recommend someone come with you at the time of your exam as a driver. Also, for your comfort, you may obtain dark glasses or inserts for your glasses at the reception desk. By signing below, you certify that you have read and understand the statement regarding dilation and wish to proceed with the eye examination


Medicare Authorization

I request the payment of appropriate, authorized Medicare benefits be made on my behalf to my physician/provider (checked above) for any services furnished to me by this physician/provider. Additionally, I authorize my medical provider to release any information about me to the Health Care Financing Administration, Centers for Medicare/Medicaid, and/or their agents that might be needed to determine any benefits payable for the services furnished. I will also permit a copy of this authorization to be used in place of the original.


Third Party Payer and/or Medicare Supplement Authorization

I request the payment of appropriate, authorized benefits be made on my behalf to my physician/provider (checked above) for any services furnished to me by this physician/provider. Additionally, I authorize my medical provider to release any information about me to the insurance carrier and/or third party medical claims administrator, covering my at the time medical services are provided, that might be needed to determine any benefits payable for the services furnished. I will also permit a copy of this authorization to be used in place of the original.


Authorization for Release/Use/Disclosure of Health Information

Dear Patient,This portion is OPTIONAL. It is to be used in the event that either the patient, or the treating physician, has a specific desire or need to release all or any portion of a patient's protected health information (a/k/a PHI)/medical record to any persons or organizations not already involved with the patient's care. This form is included with a new patient's paperwork in order to provide an opportunity for a patient to provide authorization for the Midwest Eye treating physician to share their PHI to a guardian; other family members; non-referring physician(s); and/or other parties. If you do not wish to have any of your medical information shared with anyone other than the physician that referred you to Midwest Eye Institute, YOU DO NOT NEED TO COMPLETE THIS SECTION

Please list the name of person(s) and/or Organization(s) Authorized to receive information







Limitations to this Authorization must be identified below. If this portion of the form is left blank, it is assumed that the information authorized for released is unrestricted. Please describe below any restrictions you wish to place on this authorization. (Restrictions might include limitations as to type of information released; specific dates or period of time involved; or a specific purpose for which the release might apply.)


I may see and copy the information described on this form if I ask for it, and I can receive a copy of this form after I sign it if I request one. If my physician has initiated this Authorization, I understand that in most cases I will be treated regardless of whether I sign this authorization. However, if the purpose of the Authorization is to allow research-related treatment, I understand I may not be able to get that treatment without signing this form.I hereby authorize the release / use / disclosure of my individually identifiable health information (a/k/a Protected Health Information of PHI) as described above. I understand that this authorization is voluntary. I also understand that if the person or organization authorized to receive the information is not a health plan, health care provider, or contracted business associate of this practice or Midwest Eye Institute, the released information may no longer be protected by federal privacy regulations.


Patient can set an expiration date for this Authorization in this space. Please list the expiration date below or on the occurrence of the following event:


REVOCATION (optional): This authorization may be revoked at any time by notifying your Midwest Eye Physician in writing at: Dr. __________________________ C/O Midwest Eye Institute10300 N. Illinois Street, Suite 1000 Indianapolis, IN 46290If I, as a patient or patient representative, do revoke this authorization, I understand that action will not apply to activity that occurs before the Revocation is received.

Notice of Privacy Practices

As our patient, we are offering you a copy of Midwest Eye Institute's Notice of Privacy Practices to retain for your information/reference. Copies are available on our website under patient forms, and also can be obtained at any time from our reception desk or directly from the doctor's office. If you have any comments, questions, or complaints concerning our privacy practices, you may also contact the Secretary of the Department of Health and Human Services at: Secretary of the Department of HHS200 Independence AvenueS.W. Room 509F, HHH BuildingWashington, D.C. 20201Email: ocrmail@hhs.gov You will not be retaliated against or penalized by us for making an inquiry or filing a complaint. To obtain more information concerning this notice, you may contact our Privacy Officer: Barbara BernhardExecutive Officer/Chief Operating OfficerMidwest Eye Institute, P.C. 10300 N. Illinois Street, Suite 1000Indianapolis, IN 46290Attn: Patient Privacy Request Your signature is required below indicating that the entirety of the Midwest Eye Institute Privacy Practices policy has been shared with you. By signing you also acknowledge that an actual copy of this entire policy can be obtained in various locations.


 



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