• PATIENT INTAKE FORM

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  • INSURANCE INFORMATION

  • If yes, pleases fill out the sections below.

  • Vision Insurance is for routine eye exams, and purchasing glasses or contact lenses.

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  • Medical Insurance is for diabetic eye exams, cataracts checks, eye injuries, eye infections, etc.

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  • Our office submits necessary billing and medical information to insurance companies as a courtesy. We may not be able to do this for all insurances, especially for out-of-network insurances. Copays and fees are due at time of service. Coverage is determined by your insurance company and verification of your policy is not a guarantee of coverage. Any services applied towards deductibles or deemed non-covered services are your responsibility.

  • Ocular and Health History

  • Do you or any immediate family members have any of the following eye conditions?

  • Do you or any immediate family members have any of the following medical conditions?

  • Have you had any of the following procedures?

  • HIPAA Acknowledgment

  • The Health Insurance Portability and Accountability Act (HIPAA) is a set of rules to be followed by all healthcare providers. HIPAA helps ensure that all medical records, medical billing, and patient accounts meet certain consistent standards, with regard to documentation, handling, and privacy. Please sign below to acknowledge that you've been provided an electronic or hard copy of the privacy policy from Dr. Douglas C. Kiefer & Associates, PC. 

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