Medical History Questionnaire Name: ________________________ _ Today's Date: ___________ _

Address:. ________________________ _ Phone: _____________ _

Work Phone: ___________ _

Guardian (If Applicable): _________________ _ Occupation: ____________ _

Email: _________________________ _ Preferred Language: _________ _

Birth Date: ____ _ Social Security#: __________ _ Race/Ethnicity: ___________ _

Gender: _____ _ Date of Last Eye Exam: _______ _ Date of Last Medical Exam: _______ _

Name of Medical Doctor: __________________ _ Dr.'s Phone: ____________ _

Medical History

Do you have any allergies to medications? Ono O yes If yes, explain: _________________ _

List any medications you take (include oral contraceptives, aspirin, over the counter medications and home remedies):

List all major injuries, surgeries and/or hospitalizations you have had: ______________________ _

Check any of the following that you have had: O crossed eyes O lazy eye 0 drooping eyelid O prominent eyes

Are you pregnant or nursing Ono

Do you wear glasses O no

Do you wear contact lenses? 0 no

□ yes

□ yes

□ yes

0 Glaucoma O retinal disease O cataracts 0 eye infections O eye injury

If yes, how old is your present pair of lenses? ___________ _

if yes, how old is your present pair of lenses? ___________ _

Type of contact lenses: O Rigid O Soft O Extended Wear O Other Are they comfortable? □ yes Ono

Family History: note_ any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions.

Disease/Condition No Yes ? Relationship To You Disease/Condition No Yes? Relationship TQ You

Blindness ............. ..... O 0 0 Cancer ...................... □ 0 0

Cataract .................... □ 0 0 Diabetes ........ ...... ..... □ 0 0

Crossed Eyes ........... 0 0 0 Heart Disease ........... □ 0 0

Glaucoma ................. □ 0 0 High Blood Pressure .□ 0 0

Macular Kidney Disease ......... □ 0 0

Degeneration ....... O 0 0 Lupus ........................ □ 0 0

Retinal Detachment or Disease ........... 0 0 0

Thyroid Disease ........ □ 0 0

Arthritis ..................... □ 0 0 Other:

* Please Turn This form Over & Complete Side Two * FPP 24685

Social History: This information is kept strictly confidential. You may discuss this portion directly with the doctor if you prefer.

0 Yes, I would prefer to discuss my Social History information directly with my doctor. (Check box)

Do you drive? 0 no O yes If yes, do you have visual difficulty when driving 0 no O yes if yes, please describe:

Do you use tobacco products? O no O yes If yes, type/amount/how long: _________________ _

Do you drink alcohol? O no O yes If yes, type/amount/how long: _________________ _

Do you use illegal drugs? 0 no O yes If yes, type/amount/how long: _________________ _

Have you ever been exposed to or infected with □Gonorrhea O Hepatitis 0 HIV 0 Syphilis

Review of Systems: Do you currently, or have you ever had any problems in the following areas?

System No Yes ? System No Yes ?

Constitutional Ears, Nose, Mouth, Throat

Blindness .... .......................... O Allergies/Hay Fever ............... O 0 0 D D

lntegumentary (Skin) ................ □ Sinus Congestion .................. 0 0 0

0 0 Neurological Runny Nose .......................... O 0 0

Post-Nasal Drip ..................... □ D 0 Headaches ............................ D 0 0 Migraines .............................. O Chronic Cough ...................... □ D 0

0 D Seizures ................................ □ Dry Throat/Mouth .................. D 0 0

D 0 Eyes Respiratory

Asthma ................................ .. □ 0 0 Loss of Vision ........................ O 0 0 Blurred Vision ........................ O

Chronic Bronchitis ...... ........... 0 0 0 0 0

0 0 Distorted Vision/Halos ... ........ O 0 0

Emphysema ............... ........... 0

Loss of Side Vision ............... o 0 0 Vascular/ Cardiovascular

Double Vision ........................ D Diabetes ................................ □ 0 0

0 D 0

Dryness ................................ □ 0 0 Heart Pain ............................. 0 0

Mucous Discharge ................ 0 0 0 High Blood Pressure ............. 0 0 0

Redness .... .............. .. ............ □ D 0 Vascular Disease .................. O 0 0

Sandy or Gritty Feeling ......... O 0 D Gastrointestinal

Itching ................................... □ 0 0 Diarrhea ................................ □ 0 0

Burning ................................. □ 0 D Constipation .......................... 0 0 D

Foreign Body Sensation ........ 0 0 D Genitourinary

Excess Tearing/Watering ...... D 0 0 Genitals/Kidney/Bladder ....... O 0 0

Glare/Light Sensitivity ........... 0 0 0 Bones I Joints/ Muscles

Eye Pain or Soreness ........... D D 0 Rheumatoid Arthritis ............. O 0 0

Chronic Infection, Eye or Lid . □ 0 0 Muscle Pain .......................... O 0 0

Styes or Chalazion ............ .... 0 D 0 Joint Pain .............................. O 0 0

Flashes/Floaters in Vision ..... 0 0 0 Lymphatic/ Hematologic

Tired Eyes ............ ................. □ 0 0 Anemia .................................. □ 0 0

Endocrine Bleeding Problems ................ O 0 0

Thyroid/Other Glands .... .. ... ... 0 0 0 Allergic/ Immunologic .. ..... .. ..... □ 0 0 Psychiatric ..... ...... ............. ...... ... O 0 0

If you answered YES to any of the above or have a condition not listed, please explain and list medications:

Doctor's Signature Date

(

• 1 E. 6m St. 13 07 Albion Ave. Ste. 102 Fairmont, MN 56031 A~:::,,oCIATE OPTOMETRY, P.A. Blut,.-.,darth, MN 56013

NOTICE .OF PRIVACY PRACTICES

TIIIS NOTICE OF PRIVACY PRACTICES {"NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTII INFORMATION AND HOW .YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY. Your "health Information," for plllposes of this Notice, is generally any information that lden.tifica you and is created, received, maintained or trammltted by III In the coune of providing. health care items or services to you (referred to as "health information",ln:thls Notice).

We are requ1red by the Health lmurance Portablllty and Accountability Act of 1996 {"HIPAA") and other applicable laws to maintain the privacy of your health lnfol'lll&tlon, to provide Individuals with this Notice of our legal duties and privacy p~ces with respect to such Information, and to abide by the terms of this Notice. We are also required by law-to-notify affected Individuals following a breach of their unsecured health information.

USES AND DISCLOSURES OF INFORMAT/ON:WITf{OUT YOUR A:UTHOR/ZA.TION

The most common reasons why we use or disclose your health information are for treatment, payment or health care operations. Examples of how we use or disclose your health 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 lnforination· Crom another professional that you may have seen before il,;·Examples of how we use or disclose your health information for payment PlllpOSCS ·are: asking you about' your' health or vision care plans, or other source• of payment; p~parlng 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 must carry out in order to run our office. Examples of how we use or disclose your health infonnatlon for health care operations are: financial or billing audits; internal quality assurance;

· persoMel declsiom; participation In managed care plans; defense of legal matten1 bllllnw planning; and outside storage of our record,.

OTHER. DISC!,OSURES AND USES WE MAY MAKE WITHOUT YOUR ,tUTHORIZA.TION OR .CONSENT

In some i!mitcd ·situations, the law allows or requires us to use or disclose your health Information without your consent or authorization. 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 mindatcs that certain health information be reported for a spe'clfic plllposc; for -public 'health. purposes, such as contagious disease reportlni, investigation or surveillan1:e; . and notices to and Crom the federal Food and Drug Administration reprding drugs or medical devices; disclosures io,govemmental authorities about victims ofsuspected abuse, neg1ect or domestic violence; uses and disclosures for health oversight activities, such IS for the licensing of docton; 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 1ubpoenas or orders of courts or administrative agencies; disclosures for law cnfofCC!Dcnt plllposes, such IS to provide Information about someone who ls 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 funeial directors to aid in burial; or to organizations that hBlldle orginiirtlssue ilciiwlom1 · uses or disclosures for health related research; uses and disclosures to prevent a serious threat to health or safety; uses or disclosures for speclallzcd ·govcmm~t functions, such IS for the protection of the presid~t or high ranking iovemment officials; for lawful national lntelllgeni:c activities;· for military purposes; or for the evaluation and health ofm'embm oftlirlotelgn service; · disclosures of dc-identltied lnfotmation; · ' '··· · disclosures ielating 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; dlsclosurel' to "business associarei" and their subcontractors who perform health care operations· for us and who commit to respect the privacy of your health lnfonnatlon·1n accordance with HIP AA; (specify other-llioa and disclosures affected by state law].

· Unless you object, we will abo share relevant information about your care with any of your personal representatives who are helping you with your eye care. Upon your death, we may disclose to your family members or to other persons who were Involved In your care or payment for heath care prior to your death (such as your personal representative) health inf0fD1,ation relevant to their Involvement in your care unles1 doing.an.ls l!iconsistent with your preferences as expressed to us prior to your death.

SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR A UTHORIZA.TION

The followiltg are some specific uses and disclosures we may not aialtc of your health information without your authorization:

Marketing activities. We must obtain your authorization prior to using or dlscloslng any of your health information for marketing plllpOses unless such marketing communications take the form of face-to-face communications we may make with lnd1vldua!J or prombtional gifts of nominal, value that we may provide. If such marketing involves financial payinentto us from.a_third party you,r authorization must a!Jo Include consent to such payment.

Sale of health info~oO: We do.not cu,rrently aell -.or plan to s.ell your health infonn,.tioq and. we:must_ scck,your.a,11tho~on prior. to doing so.

Psychotherapy notes, Although we do not create or maintain psychotherapy notes on our patients, we are required to notify you that we generally niust obtain your authorization prior to using or disclosing any such nolf", ·

YOUR RIGHTS TO PROYIDE AN A UTHORIUTION FOR OTHER USES AND DISCLOSURES

Oilier uses and dlsclos~ of your health Information that arc not described In thla Notice will be made only with your written authorization. /1 }·~

You may ·a1sve ui'wr!ttett authorization permitting us to use your heafth Information or to disclose it t~ anyone 'for any plllpOse.

v.2013.05.17

1307 Albion Ave. Ste. 102 ,. 1 E. 6th St. Fairmont, MN 5603l ~CIATE OPTOME.tRY, P.A. B~arth, MN 56013

We will cibtiln your ~ttcii authorization·ror Ille, 111d diac;losuia•o(youi hcalth".illfotmiltion that arc nor·ldcntified in thia Notice or arc not otherwise permitted by applicable law. ·

Wc·milst aarcc-to your reque11t to rc,trict disclosure of your health illformatioll to I health plan !(the disclosure is for the purpose of carrying out payment or health ·care opcratlom and is not otherwise required by "law and l\lch· lllfoitliatlon pertains iolcly to a health care Item or service for which you have paid in 1iill ( or for w]l!ch another pcnon other·than the health plan bu paid in full on )'0111' behalf).

Any authorization ybu provide to us regarding the use-and disclo1urc of your htlilth illformition may be revoked by you in writing at any time. After you n:voke your authorization, we ~Ill no lo~ct use or-disclose your health,illformationJo(_the ~0!11 described In the authoriza!fon. However, we arc genc:rally unable to n:tract any disclosures that we may have already made with your authorization. We may also be required to disclose health Information as necessary for purposes of payment for services received by you prior to the date you revoked your authorization.

· YOUR INDIYIDUAL RIGHTS

You litv'«!lliuiy rlahti'coirccriifutthe··C'onfldeiltlail(y of your heilth Information. You have the right:

To request reatrictlons' on ibe health Information we may use and disclose for trea~ent, payment and health care operations. We arc not reguin:d to agree to _these requeslJ. To request restrictions, please send a written request to us at the address below.

• · · To receive confidential communications of health Jnformation about.you.In any manner other than desc.:ribcd In, our authorization request form. You must make such requeslJ in writing to the address below. However, we reserve the right to determine if we will be able to continue your treatment under such restrictive authorizations.

To· Inspect or COJlY your helllt!Hiifoi:matlon. You must make such requasts In-writing to the address below. If you request a copy of your health infonnation we may charge you t"fee·for·the cost of copying. malllng'or other,supplludn certain circumstances we may deny your request to Inspect or copy your health Information, 111bjcct tcrappllcable law. · ·

Tci-~tnd'hcalth imoiiriifion. If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information. To request an am~dment, you must write to us at the address below, -You must also give us a reason io support your request. We may deny your l'C'!Ucst to amend your health-lnformatlon if It b not in writing or docs not provide i reason to support your request. We may also deny your request if the health infonnatlon: • .

o wa,not creatccfby us, unless the person that created the lnfo_~~n ls no loligcr available to make the amendment,

o . . is ~ot part ofth~-health information kepfi,y or for us, .: ·; .. .. ·_,,, .... :

o . :. is not part of.the Information you would be permitted to inspect or,copy, or

o .·· .. ;incclli'atc and'CODl.plete,,-·' ·· .

To ~Ive ill-~tliia of d!Jclb-illm of your healtliinforil11ti'on: Yoii aiUJt make such requests in writing to the address liclow. Not all health information is Jlibject to tli1J requoat. Yout rcqucst'ntust state• tinic1set10-d for the lnfonnatlon you would like to receive, no longer than 6 years prior to the date of your request and may not include dates before April 14, 2003. Your reque1t must state how you would like to receive the report (paper, electronically).

To designate another puty to receive your hcaiiii infornWion. If your requat for ~cccss of your health information directs us to ~ta copy of the health information directly to._anothcr person the request must bc_madc by you In wrltln& to the addras below and must clearly. identify the designated recipient and where to send the copy of the health information.

ContactPer1on: ·:.• ··. ·,~ , -- .-::,·, .:: ... ~: ·:·• -·· :·:_: ,_;,.;, .. :,

Our contact pmon''fot ill qu~ti6111,•~iiestt'Or-foH\irtlii::r·inf~nnatioti1iil~to~l'to·1h .. prlvacy of your hwth information is: · Jim-es•Biilclie;'O:I>;;,.•·:. ·· · .. :·_-1307 · _ ·: 'Albion Ave., Ste 102; Fairmont,·MNS6031

Complalni1:

If you thiillc that we have not properly respected the privacy ofyour:hcalth illformatlon, you arc free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We wl1f1lot ietaliate against you if you make I eo111plalnL If you want to complain to us, send a written complaint to the office contact person at the address, (ax or Email shown above. If you prefer, you can disc:uJI your complaint in pcnon or by phone.

Chqngu to'Thi.rNotict: · ..

W c reserve the right to change our prlvticy practices and to apply the revised pnctl«a to health Information about you that we already have. Any revision to our privacy practices-will be described In a-revised Notice that will be posted prominently In our facility, Copies of this Notice arc also available upon request at our reception area.

,'' :.·.: Notice Revised"lliid Effc:cilvc·: ·''September %3\i'.2013).• ·'.. · · · · · .,. ':_ •·· :·· , .. ·: ,·

- - · - - · - - ..:..... • ..i._ : •• ' ··: •: : • , ; .. ~. ; ., ; • • :·· • • • , •. ••

Patient Signature Date

v.2013.05.17

ASSOCIATE OPTOMETRY, P.A. CONFIDENTIAL PATIENT INFORMATION RECORD

NAME BIRTH DATE ----:-::------------------- ---------------(first Ml last) ADDRESS ______________ CITY/STATE/ZIP _____________ _

HOME PHONE # _________ CELL PHONE# _________ MALE FEMALE __

ARE YOU: SINGLE __ MARRIED WIDOWED DIVORCED MEDICARE# ________ _

EMPLOYER ___________ OCCUPATION ________ WORK PHONE# ____ _

EMPLOYER ADDRESS ______________ CITY/STATE/ZIP __________ _

IF STUDENT, NAME OF SCHOOL/COLLEGE ______________ CITY _______ _

WHO CAN WE THANK FOR REFERRING YOU? _____________________ _

EMERGENCY CONTACT NAME ________________ PHONE# _______ _

MAY WE CONTACT YOU VIA E-MAIL? NO YES E-MAILADDRESS: ____________ _

BILLING INFORMATION

NAME OF PERSON RESPONSIBLE FOR ACCOUNT _________ RELATIONSHIP _____ _

ADDRESS ___________ CITY/STATE/ZIP ________ PHONE# _______ _

PARENT/SPOUSE NAME __________ PARENT/SPOUSE EMPLOYER _________ _

ADDRESS CITY/STATE/ZIP PHONE# - ------------ ------- -------HEALTH INSURANCE INFORMATION

NAME OF INSURED _________ RELATIONSHIP TO PATIENT _____ BIRTHDATE ____ _

INSURED'S EMPLOYER IF GROUP POLICY _______________ PHONE# ____ _

INSURANCE COMPANY NAME _ _______ ID# _ ___ _ _____ GROUP# ___ __ _

COMPANY ADDRESS __________ CITY/STATE/ZIP _____________ __ _

DO YOU HAVE ROUTINE VISION CARE COVERAGE WITH THIS COMPANY? --------------1 F YOU HAVE ADDITIONAL COVERAGE, PLEASE LIST ON BACK OF FORM.

Your vision care account will be billed to you and is payable by you, under the terms of our credit policy. We accept assignment from many major insurance

providers, however, some insurance plans will make payment to you to cover all or part of the charges according to their policy coverage. Complete your

portion of any claim form, and we will complete the necessary claim procedures as instructed.

HOBBIES OR OCCUPATIONAL DATA THAT COULD AFFECT YOUR VISION NEEDS (please circle) COMPUTER CONSTRUCTION BOOKKEEPING READING WELDING SPORTS HUNTING FISHING SEWING MUSIC other _______ _ ___ _______________________ _

LIST ANY SPECIAL CONCERNS OR QUESTIONS YOU HAVE ABOUT YOUR VISION. _ ___ __________ _

*PLEASE READ AND SIGN THE CREDIT AGREEMENT ON REVERSE SIDE OF THIS FORM.

AGREEMENT In consideration of treatment by the doctor, the undersigned agrees:

1. To pay the amount charged by the doctor for all professional treatment and services to the undersigned, his/her family, or to the patient indicated above, for vision care including initial and subsequent materials and services required for spectacles and/or contact lenses.

2. To order eyewear or contact lenses, we require one-half of the balance down, with the remaining balance due upon dispense.

3. That after an account is 30 days past the date of service, to pay a finance charge which is computed by a periodic rate of 1 1 /2% per month. This is an annual percentage rate of 18% applied to the balance over 30 billing days after deduct­ing current payments and/or credits appearing on your statement. This allows for a minimum of 30 days from date of service to pay for your account without incurring a finance charge.

4. To pay all finance charges in the event agreement is not kept. 5. Responsible party is patient or the parent or guardian requesting examination or treatment of minor.

CREDIT POLICY To enable you to obtain vision care when you need it, without creating a financial burden, it is the usual policy to extend limited credit to our patients. Credit arrangements must be made at the time of exam and/or order.

1. Several major credit cards are accepted. 2. Financing is available through CareCredit. (Staff can provided applications and details.) 3. All charges are considered "past due" 40 days after the date they are incurred. Any balance over 30 days shall be

subject to a finance charge computed at the interest rate of 1 1/2% a month (18% annually), based upon the minimum outstanding balance of the month. A minimum finance charge of 50 cents per month will apply.

4. If, due to the amount of your account balance, full payment creates a financial burden, your account may be paid in three equal payments plus 11/2% of the minimum outstanding balance per month, or 50 cents minimum finance charge. These arrangement must be made at the time of exam and/or order.

5. If special circumstances arise, we will be glad to work out an acceptable payment arrangement for your account; however, if no payment or arrangements for payment have been made in a 60-day period, the next billing will show a past-due notice.

6. If payment or arrangements for payment are not made, the account will be transferred to a professional collection agency. 7. You agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of

33% of the debt, and all costs, and expenses, including reasonable attorneys' fees, we incur in such collection efforts. We recommend and appreciate full cash payment at the time of exam and/or order. Prompt pay discounts may apply. We require full payment for contact lenses upon dispense.

I have read and understand the above agreements and credit policies.

(signature of patient or responsible party) (date)

FPP-21 288