Registration

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For patients accessing our portal for the first time, please contact our office.


LuxSci: Secure communications

Personal Information

Gender:

Language:

Marital Status:

Ethnicity:

Race:

Contact Information

Preferred Method of Contact:

Minor Information

Student Status:

Caregiver Information (if applicable)
Patient or Parent/Legal Guardian Employment Information

Employment Status:

Emergency Contact Information
Responsible Party Information

Responsible Party:

Referring Physician & Pharmacy Information
Referral Information
Medical/Vision Insurance Information

Do you have medical insurance to cover your examination or treatment?

Do you have vision insurance to cover your examination or treatment?

Does your insurance company require a formal authorization or referral from a primary care physician for our services?

Accident Information

Is your treatment for an injury or accident?

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.

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.

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:

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:
Surgical/Hospitalization History List all surgeries or hospitalizations in the last 10 years, including prior eye surgeries, and the date of each one:
Medication History Please list all medications you are currently taking (including dosage)

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Allergens Please list all medications you are allergic to:
Are you allergic to any of the following?:

If Yes, please select all that apply:
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

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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: