Registration Home Registration Patient Portal For patients accessing our portal for the first time, please contact our office. LuxSci: Secure communications Step 1. Personal Information Step 2. Medical History Step 3. Financial Policy Personal Information First Name: Middle Name: Last Name: Social Security #: Date of Birth: Age: Address: Today's Date: Gender: Female Male Language: English Spanish Other If other language: Marital Status: Single Married Divorced Widowed Separated Minor Child Ethnicity: Hispanic or Latino Not Hispanic or Latino Unknown Decline to Answer Race: American Indian or Alaska Native Asian Black or African American White or Caucasian Native Hawaiian or Other Pacific Islander Other Decline to Answer Contact Information Home Phone Number: Work Phone Number: Mobile Phone Number: Preferred Method of Contact: Mobile Home Work Email Address: Minor Information Lives with (Name): Lives with (Relationship): Student Status: Full-Time Part-Time Not a Student Caregiver Information (if applicable) Caregiver Name Caregiver Phone Number School Name: School Address: Spouse Information Spouse's Name: Spouse's Date of Birth: Spouse's Social Security #: Spouse's Employer: Spouse's Address: Spouse's Phone: Patient or Parent/Legal Guardian Employment Information Employment Status: Full-Time Part-Time Not Employed Retired Employer Name: Employer Address: Occupation: Emergency Contact Information Emergency Contact Name: Emergency Contact Relationship to Patient: Emergency Contact Address: Emergency Contact Primary Phone: Emergency Contact Alternate Phone: Responsible Party Information Responsible Party: Self Guarantor Responsible Party First Name: Responsible Party Middle Name: Responsible Party Last Name: Responsible Party Relationship to Patient: Responsible Party Address: Address same as patient Responsible Party Home Phone: Responsible Party Work Phone: Responsible Party Mobile Phone: Responsible Party Date of Birth: Responsible Party Social Security #: Responsible Party Employer Name: Responsible Party Employer Address: Referring Physician & Pharmacy Information Name of Referring Physician: Referring Physician Phone: Name of Family/Primary Care Physician: Family/Primary Care Physician Phone: Family/Primary Care Physician Address: Preferred Pharmacy Name: Preferred Pharmacy Phone: Preferred Pharmacy Address: Referral Information How did you hear about our office? --Select One-- Television Movie Theatre Online Newspaper Doctor Referral Friend or Family Other Medical/Vision Insurance Information Do you have medical insurance to cover your examination or treatment? Yes No Medical Insurance Company Name: Medical Insurance ID: Do you have vision insurance to cover your examination or treatment? Yes No Vision Insurance Company Name: Vision Insurance ID#: Does your insurance company require a formal authorization or referral from a primary care physician for our services? Yes No If Yes, Physician's Name: Name of policy holder: Relationship to patient: Date of Birth: Accident Information Is your treatment for an injury or accident? Yes No Were you injured at work? Yes No Is this covered by Workers' Compensation? Yes No Contact Person at your Employer: Name of physician who treated you at time of accident: Date of Accident: Time of Accident: Location of Accident: How did the injury happen? Release of Information I authorize the release of any medical information necessary to process insurance claims, and I authorize payment of medical benefits to Indiana Eye Clinic. I am financially responsible for all services provided by Indiana Eye Clinic to me or my dependents. If Indiana Eye Clinic is not a participating provider in my insurance plan, I understand that payment is required at the time of service. If my insurance requires a referral from my primary care physician, I will provide the referral at the time of service. I agree 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 payor. If for any reason my account should become delinquent, I am liable to pay all collection and legal fees. I agree Release of Medical Information On occasion a family member, friend, or caregiver may contact the Indiana Eye Clinic to inquire about your medical information. Please list authorized individuals to whom your information may be disclosed: Authorized Individual #1 Name: Authorized Individual #1 Relationship: Authorized Individual #2 Name: Authorized Individual #2 Relationship: Authorized Individual #3 Name: Authorized Individual #3 Relationship: Authorized Individual #4 Name: Authorized Individual #4 Relationship: Medical History Medical History Select Yes if you have any of the following conditions listed in the table below: Yes No Medical Condition High Blood Pressure Diabetes Cancer Heart Disease Breathing Problems Kidney Disease Circulation Problems Ear/Nose/Throat Stomach Problems Neurological Disorders Psychiatric Disorders Skin Disorders Allergic/Immune Thyroid Migraines/Headaches Muscle/Skeletal Other Have you had your flu shot? Have you had your pneumonia shot? Do you drink alcohol? Do you live alone? Are you pregnant? Family/Medical Doctor(s) History List your last two family/medical doctors: Doctor #1 Name: Doctor #1 Phone: Doctor #2 Name: Doctor #2 Phone: Surgical/Hospitalization History List all surgeries or hospitalizations in the last 10 years, including prior eye surgeries, and the date of each one: Surgery #1: Surgery #2: Surgery #3: Surgery #4: Surgery #5: Surgery #6: Surgery #7: Surgery #8: Medication History Please list all medications you are currently taking (including dosage) Medication #1 Name: Dosage: Frequency: How Taken: Medication #2 Name: Dosage: Frequency: How Taken: Medication #3 Name: Dosage: Frequency: How Taken: Medication #4 Name: Dosage: Frequency: How Taken: Medication #5 Name: Dosage: Frequency: How Taken: Medication #6 Name: Dosage: Frequency: How Taken: Medication #7 Name: Dosage: Frequency: How Taken: Medication #8 Name: Dosage: Frequency: How Taken: Allergens Please list all medications you are allergic to: Medication #1 Name: Medication #2 Name: Medication #3 Name: Medication #4 Name: Are you allergic to any of the following?: No Yes If Yes, please select all that apply: Latex Rubber Eggs Soybeans Peanuts Other Ocular History Have you been diagnosed with any of the following in the past? Yes No Medical Condition Date/Comments Cataracts Retinal Disorder Crossed Eyes Corneal Disease Glaucoma Injury Other Eye Disorders Eye Surgery Family History Has anyone in your family had any of the following? Please note relation to patient: F - Father, M - Mother, P - Paternal, MA - Maternal, S - Sister, B - Brother, GF - Grandfather, GM - Grandmother Yes No Medical Condition Relation(s) Cataracts Retinal Disorder Glaucoma Heart Disease Diabetes Hypertension Other Eye Problems Other General Health Problems E-Newsletter Would you like to receive our e-newsletter? Yes No Any other information: Personal Information Financial Policy Financial Policy (Sign at bottom of page) Thank you for allowing Indiana Eye Clinic to be your healthcare provider. IEC is committed to the success of your medical treatment and care. Our practice will work with you to help meet your payment responsibility. We will file medical claims for you, and it is imperative that you provide us with accurate insurance information at your appointment (we must copy your insurance cards). If you do not provide insurance information, you will be Self Pay and required to pay in full during your visit. It is important to understand you have the contract with your insurance provider and you need to help us work with your insurance to expedite payment. You are responsible for unpaid balances not covered by insurance. You have final responsibility for payment of services provided. Privacy Practices: Indiana Eye Clinic maintains a Notice of Privacy Practices dedicated to the protection of our patient’s health information. Managed Care Plans:Some insurance plans require a referral from a Primary Care Physician or pre-certification before treatment by a Specialist. If you were required to obtain this referral, but did not obtain it, you will be responsible for payment or reschedule your appointment. All co-pays are due at time of service. Non-Covered Services: We continuously adapt to health insurance carriers’ changing policies. We offer services superior to convenient treatment, and some services provided may not be considered medically necessary or may not be a covered benefit by your specific policy. You, the patient, are responsible for payment at the time of service for all services not covered by insurance. Refraction Fee and Other Fees: Refractions are tests to obtain best corrected vision to determine the need for eyeglasses, surgery and/or medicines. Most medical insurance plans including Medicare do not pay for Refractions. We will collect refraction fees of $40-$55 at the time of service. Additional tests and/or contact lens fittings may not be covered under your insurance plan. Missed Appointments:: IEC may charge a fee for missed appointments when patients fail to give appropriate notification. Cancellation notice must be received twenty-four (24) hours in advance of the appointment. A $25.00 charge may be applied for failure to meet this requirement. Returned Check: IEC will charge a $20.00 fee for each check returned for non-sufficient funds. Disability/FMLA/Other Forms:IEC charges $25.00 for completion of each form.Payment is required prior to completion of any form. Collection Agencies:Should it become necessary for IEC to send a patient’s account to a collection agency, the patient is responsible for all fees associated with collection efforts including reasonable attorney fees, court costs, collection charges and interest, as allowed by law. I have read and understood this Financial Policy. I understand the terms and conditions outlined herein as confirmed by my signature. Signature: You must complete the captcha before you can submit! Medical History Submit