New Patient Form If you would prefer to print this form, please use this link. Welcome to Our OfficeWe are committed to providing you with a great customer experience and are happy to verify insurance eligibility and benefits. However, this is never a guarantee of benefits as some insurance companies arbitrarily select certain services that they will not cover and/or must be medically necessary. It is your responsibility to understand the scope and limitations of your insurance policy and you are financially responsible for all charges rendered whether or not paid by your insurance. We are happy to discuss insurance coverage in more detail with you regarding your specific vision and/or medical plan. Insurance Blink Eyecare are providers for numerous vision/medical insurance panels. Your responsibility will be for any co-payment and other charges your insurance does not cover. Our office will help you receive your maximum benefits, if you have provided us with the necessary current insurance information at the time of examination, or before the time your eyewear is ordered. Otherwise, you will be responsible for all costs incurred. If your insurance plan requires a co-payment/co-insurance, you are expected to pay this at the time of service. If your insurance company has not paid the balance within 60 days of service, and it is determined that they will not be paying, you will have 30 days to pay the balance. Should the account be referred for collections, you will be responsible for collection fees and expenses. If we do not accept your vision/medical insurance, then you will be responsible for all fees and charges that you incur. Payment is due the day of the examination unless prior arrangements have been made. Our office will provide you with an itemized statement that you can submit to your insurance company for reimbursement upon request. Uninsured Patients If you do not have insurance for services provided, a 30% administrative discount will be given if the account is paid in full on the day of service. This applies to services only; glasses, contacts and other eyewear are not included. Payment We accept cash, check, Visa, MasterCard and Discover. A $30.00 returned check fee will be assessed for any returned checks. We also accept Carecredit. Medical Services For medical care, if you have not met your deductible, we will collect half of your balance at the time of service. You will receive a bill for the remaining balance after your insurance processes your claim unless other arrangements have been made. Refraction Services During refraction, the Optometrist evaluates whether you would benefit from corrective eyeglasses. The refraction service is vital to calculating the most accurate prescription to help your vision. Medicare and most other medical insurance do not cover refraction as part of their medical policies. If you have a separate vision plan outside of your medical insurance, please let us know, as many vision programs will pay for the refraction. By signing below, I agree I have read the refraction policy and understand that this is considered a non-payable service by most insurers and I agree to pay the $65.00 cost at the time of service. Contact Lens Prescription Rule This rule states that the patient must acknowledge receipt of their contact lens prescription. I understand and acknowledge that once my contact lens exam is completed and finalized within 90 days, I will be given a copy of my contact lens prescription in a paper format or digital. I understand that if I request an additional copy of my prescription that Blink Eyecare has 40 business hours to respond and provide me with a new copy. By signing below I acknowledge that I will be given a copy of my prescription once I am finalized. 92310 Contact Lens Exam Services Contact lens exam services are not covered by most insurances. All contact lens follow ups must be completed within 90 days or a new exam will be necessary. If I choose to have these services and they are not covered by my insurance, then I understand that I am financially responsible. Single Vision Fitting: $80.00 Astigmatism Fitting: $98.00 Multifocal Fitting: $150.00 New Wearer Fitting: $150.00 RGP Single Vision/Toric Fitting: $150.00 RGP Multifocal Fittings: $165.00Specialty Contact Lens Fittings: $200.00 Eyewear/Contact Lenses We strive to provide you a truly custom product, tailored to your individual prescription. Therefore, frame and lenses are not-refundable. However, store credit will be honored within 30 days of being dispensed. 50% down payment is required to order glasses or contact lenses, the balance is due when they are dispensed. If the glasses/contacts are not picked up within a month then you will receive a statement and will need to pay off your balance within 60 days. Otherwise your account will be turned over to collections. Collections Accounts with balances over 90 days old are considered “Past Due.” Our billing staff will make a reasonable attempt to notify you if your account has reached a “Past Due” status. It is important that all changes in your name, address, phone number, insurance, or employment be relayed to our office as it can affect the billing of your account. If we are unable to locate a patient, payment is not received, or satisfactory payment arrangements are not made, then an account will be referred to our collection agency. Should this occur the patient will be responsible for collection fees and expenses. If you had eyewear purchased and the balance was sent to collections, you will not be able to pick up your eyewear until your collection balance has been paid off. Then any future orders will have to be paid in full to be ordered. Once you have been sent to collections, we can no longer collect any fees/money. You will need to contact the collection agency and pay them. We will also not be able to see you for any future appointments until your previous balance has been paid off. Lack of Cooperation We are grateful for all our patients and the opportunity to serve them. We appreciate your assistance in helping us complete our work in an efficient and accurate manner. We believe that all patients should be treated with dignity. We reserve the right to terminate a patient from the practice in those rare cases when a patient may be verbally or physically abusive, refuse to give necessary information, or is non-compliant with ocular instructions, treatment and advice, or in collections. Read through our HIPAA Policy Form Here.* I acknowledge that I have been offered a copy of this agreement. * I acknowledge that I have had the opportunity to read over the patient care agreement & privacy practice policies of Blink Eyecare. I agree to pay for any non-covered services, copays, coinsurances at the time of service. I understand that if my balance is not paid in full within 90 days that I will be turned over to collections unless other arrangements have been made. This policy is effective the date it is signed and for future services/purchases. Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Your E-Signature*Patient Name* First Last Address* Street Address Apt/Suite City State Zip AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone Number* Is this a cell phone number? Yes No Email* Enter Email Confirm Email Race American Indian African American Asian Pacific Islander White Ethnicity Hispanic or Latino Non Hispanic or Latino Patient SSN Do you have insurance?* Yes No We offer a 20% discount to our cash-paying patients!Please upload a copy of your medical and vision insurance cards. Note: VSP may not have its own card, please use your medical card. Drop files here or Select files Max. file size: 2 MB. Employer (or school)* Job Title (or Grade)* Spouse's Name (or Parent's Name) Purpose of this visit Did anyone refer you to our practice? Yes No Who referred you to us? Name of Family Physician Date of Last CheckupMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you being treated for any medical conditions? Yes No What condition(s)? Current Medications (Rx or Over the Counter)Are you allergic to any medications?* Yes No What medications? Do you use alcohol?* Yes No Do you use tobacco?* Yes No Smoking Status* Current Former Never Patient Eye HistoryDate of Last Eye ExamMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920By whom? Have you ever tried contact lenses? Yes No Do you currently wear contact lenses? Yes No What Brand? R Power L Power R Base Curve L Base Curve R Diameter L Diameter Right Eye CYL Right Eye Axis Left Eye CYL Left Eye Axis What solutions do you use? Have you ever experienced, been diagnosed or treated for any of the following? Blurry Vision Burning Cataracts Corneal Abrasions Crossed Eye/Eye Turn Double Vision Eye Infections Eye Injury Eye Surgery Flash of Light Floaters/Spots Glaucoma Grittiness Headaches Iritis/Uveitis Lazy Eye Macular Degeneration Occasional Dryness Retinal Detachment Sunlight Sensitivity Tearing Trouble seeing at night Uncomfortable Glasses No Other Please describe Has anyone in your family ever been diagnosed for the following conditions? Cancer Cataracts Diabetes Glaucoma High Blood Pressure Hyperthyroidism Hypothyroidism Macular Degeneration No Other Please explain the family relation for the condition(s) selected. Do you… (check all that apply) …think you might benefit from thinner, lighter lenses? …have interest in trying the latest contact lens designs? …spend significant time outdoors? …have prescription sunwear? …prefer not to wear your glasses at times? …want information on Laser Vision Correction surgery? …have more than one pair of Rx eyewear? …have family members in need of eyecare? CommentsThis field is for validation purposes and should be left unchanged.