Patient Forms

​​​​​​​How were you referred to our office? *

Personal Vision History

Have you ever been diagnosed with the following? *

​​​​​​​Do you currently wear contact lenses?​​​​​​​
Please check all that apply *

Are you currently taking any medications?
If so please list them below *

Are you allergic to any medications?​​​​​​​
If so please list medication allergies below *

​​​​​​​Are you currently pregnant? *

​​​​​​​Are you experiencing headaches? *

​​​​​​​Have you ever been diagnosed with any of the following?​​​​​​​
Please check all that apply *

​​​​​​​Has anyone in your immediate family been diagnosed with any of the following?​​​​​​​
Please check all that apply *

Vision Insurance vs. Medical Insurance *​​​​​​​
We often have patients that have both vision and medical insurance. They are very different in terms of the services they cover and it’s important for our patients to understand those differences. Vision coverage is mainly designed to determine a prescription for glasses, and to evaluate the health of their eyes. It is not equipped to deal with complex medical conditions, diagnoses, and/or treatment plans. When a medical diagnosis or condition is present (such as high blood pressure, diabetes or eye disease) it is necessary to file the visit with your major medical carrier and the co-pays for that insurance will apply as well as any non-covered service. Our office does not make these rules and they are defined by the insurance carriers themselves. There is no way to know prior to the examination which type of insurance our office will be able to file for you. We make every effort to be on every major carrier for your convenience and we will file those claims for you. In the event that we do not take your major medical/vision insurance, we will provide you with an itemized receipt so that you may file with your carrier for reimbursement. If you have any questions, please let us know. I understand the paragraph above and authorize Allen E Austin OD Inc. to file my insurance.
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Authorization of Payment *
I understand that billing my insurance is a service that this office provides and that therefore: I hereby authorize this eye care provider to apply for benefits on my behalf for services rendered by them. I authorize the release of any medical or any information necessary to process this claim. I authorize payment of benefits directly to this provider. I understand that benefit authorization is not a guarantee of payment and that I am ultimately responsible for all services and material fees and full payment of any balance that is not covered by my insurance.
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Privacy Policy *​​​​​​​
Notice of Privacy Practices

ALLEN E AUSTIN OD INC

THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”) DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN GET ACCESS TO SUCH INFORMATION. PLEASE READ IT CAREFULLY.

Your “health information,” for purposes of this Notice, is generally any information that identifies you and is created, received, maintained or transmitted by us in the course of providing health care items or services to you (referred to as “health information” in this Notice).

We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other applicable laws to maintain the privacy of your health information, to provide individuals with this Notice of our legal duties and privacy practices 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 INFORMATION WITHOUT YOUR AUTHORIZATION

The most common reasons we would use or disclose your health information is for treatment, payment, or business operations. We routinely use and disclose your medical information within the office on a daily basis. We do not need specific permission to use or disclose your medical information in the following matters, although you have the right to request that we do not.

Examples of how we might use or disclose health information for treatment purposes might include:

Setting up or changing appointments including leaving messages with those at your home or office who may answer the phone or leaving messages on answering machines, voice mails or emails; calling your name out in a reception room environment; prescribing glasses, contact lenses, or medications as well as relaying this information to suppliers by phone, fax or other electronic means including initial prescriptions and requests from suppliers for refills; notifying you that your ophthalmic goods are ready, including leaving messages with those at your home or office who may answer the phone, or leaving messages on answering machines, voice mails or emails; referring you to another doctor for care not provided by this office; obtaining copies of health information from doctors you have seen before us; discussing your care with you directly or with family or friends you have inferred or agreed may listen to information about your health; sending you postcards or letters or leaving messages with those at your home who may answer the phone or on answering machines, voice mails or emails reminding you it is time for continued care.

Examples of how we might use or disclose health information for payment purposes might include:

Asking you about your vision or medical insurance plans or other sources of payment; preparing and sending bills to your insurance provider or to you; providing any information required by third party payors in order to insure payment for services rendered to you; collecting unpaid balances either ourselves or through a collection agency, attorney, or district attorney’s office. At the patient’s request, we may not disclose health care information for services that you have paid for out of pocket. This only applies to those encounters related to the care you want restricted.

“Health care operations” mean those administrative and managerial functions that we must carry out in order to run our office. Examples of how we might use or disclose health information for health care operations might include:

Financial or billing audits; internal quality assurance programs; participation in managed care plans; personnel decisions; defense of legal matters; business planning; certain research functions; informing you of products or services offered by our office; compliance with local, state, or federal government agencies request for information; oversight activities such as licensing of our doctors; Medicare or Medicaid audits.

OTHER DISCLOSURES AND USES WE MAY MAKE WITHOUT YOUR AUTHORIZATION OR CONSENT

In some limited 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 mandates that certain health information be reported for a specific purpose
For public health reasons, such as reporting of a contagious disease, investigations or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices
Disclosures to government or law authorities about victims of suspected abuse, neglect, domestic violence, or when someone is or suspected to be a victim of a crime
Uses and disclosures for health oversight activities, such as for the licensing of doctors; 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 subpoenas or orders of courts or administrative agencies
Disclosures for law enforcement purposes, such as to provide information about someone who is 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;
Disclosures to a medical examiner to identify a deceased person or determine cause of death or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; Uses or disclosures for health related research
​​​​​​Uses or disclosures to prevent a serious threat to health or safety of an individual or individuals
Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
Disclosures of de-identified information
Disclosures related 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 and disclosures
Disclosure of information needed in completing form from a school related vision screening, information to the Department of Public Safety, information related to certification for occupational or recreational licenses such as pilots license.
Disclosures to “business associates” and their subcontractors who perform health care operations for Allen E. Austin OD Inc. and who commit to respect the privacy of your health information in accordance with HIPAA​​​​​​​.

Unless you object, we will also 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 information relevant to their involvement in your care unless doing so is inconsistent with your preferences as expressed to us prior to your death.

USES OR DISCLOSURES TO PATIENT REPRESENTATIVES

It is the policy of Allen E Austin OD Inc for our staff to take phone calls from individuals on a patient’s behalf requesting information about making or changing an appointment; the status of eyeglasses, contact lenses, or other optical goods ordered by or for the patient. Allen E Austin OD Inc staff will also assist individuals on a patient’s behalf in the delivery of eyeglasses, contact lenses, or other optical goods. During a telephone or in person contact, every effort will be made to limit the encounter to only the specifics needed to complete the transaction required. No information about the patient’s vision or health status may be disclosed without proper patient consent. Allen E Austin OD Inc staff and doctors will also infer that if you allow another person in an examination or treatment room with you while testing is performed or discussions held about your vision or health care that you consent to the presence of that individual.

SPECIFIC USES AND DISCLOSURES OF INFORMATION REQUIRING YOUR AUTHORIZATION

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

Marketing activities. We must obtain your authorization prior to using or disclosing any of your health information for marketing purposes unless such marketing communications take the form of face-to-face communications we may make with individuals or promotional gifts of nominal value that we may provide. If such marketing involves financial payment to us from a third party your authorization must also include consent to such payment.

Sale of health information. We do not currently sell or plan to sell your health information and we must seek your authorization prior to doing so.

YOUR RIGHTS TO PROVIDE AN AUTHORIZATION FOR OTHER USES AND DISCLOSURES

Other uses and disclosures of your health information that are not described in this Notice will be made only with your written authorization, the signing of a written Authorization for Release of Identifying Health Information. You may give Allen E Austin OD Inc written authorization permitting us to use your health information or to disclose it to anyone for any purpose.

We will obtain your written authorization for uses and disclosures of your health information that are not identified in this Notice or are not otherwise permitted by applicable law.

We must agree to your request to restrict disclosure of your health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law and such information pertains solely to a health care item or service for which you have paid in full (or for which another person other than the health plan has paid in full on your behalf).

Any authorization you provide to us regarding the use and disclosure of your health information may be revoked by you in writing at any time. After you revoke your authorization, we will no longer use or disclose your health information for the reasons described in the authorization. However, we are generally unable to retract 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 INDIVIDUAL RIGHTS
You have many rights concerning the confidentiality of your health information. You have the right:

• To request restrictions on the health information we may use and disclose for treatment (except in emergency care), payment and health care operations. We are not required to agree to these requests. To request restrictions, please send a written request to us at the address below.
• To receive confidential communications of health information about you in any manner other than described in our authorization request form. You must make such requests 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 copy your health information. You must make such requests in writing to the address below. If you request a copy of your health information we may charge you a fee for the cost of copying, mailing or other supplies. Health care information you request may be delivered to you in electronic format. The e-formats supplied by Allen E Austin OD Inc have been approved to be secure and protect the integrity of your health care information. Such e-formats include secure email and an authorized Electronic Health Information system and media. In certain circumstances we may deny your request to inspect or copy your health information, subject to applicable law.
• To amend health information. 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 amendment, you must write to us at the address below. You must also give us a reason to support your request. We may deny your request to amend your health information if it is not in writing or does not provide a reason to support your request. We may also deny your request if the health information was not created by us; unless the person that created the information is no longer available to make the amendment; is not part of the health information kept by or for us; is not part of the information you would be permitted to inspect or copy; or is not accurate and complete.
• To receive an accounting of disclosures of your health information. You must make such requests in writing to the address below. Not all health information is subject to this request. Your request must state a time period for the information you would like to receive, no longer than 6 years prior to the date of your request and may not include dates before January 1, 2007. Your request must state how you would like to receive the report (paper, electronically). You are entitled to one such list per year without charge. If you want more frequent lists, you must pay for them in advance at a fee of $30.00 per list. We will usually respond to your written request within thirty (15) days but we are allowed one thirty (30) day extension if we need the time to complete your request.
• To designate another party to receive your health information. If your request for access of your health information directs us to transmit a copy of the health information directly to another person the request must be made by you in writing to the address below and must clearly identify the designated recipient and where to send the copy of the health information.

You may obtain additional copies of this Notice of Privacy Practices from our office or online at our website address shown below.

Contact Person, Privacy Official:
Our contact person for all questions, requests or for further information related to the privacy of your health information is:
Allen E. Austin O.D .
One City Boulevard West #111
Orange, California 92868
PHONE 714-634-0033
FAX 714-634-2277

Complaints:

If you think that anyone at Allen E Austin OD Inc has not properly respected the privacy of your health information, you are free to complain to the practice Privacy Officer named above. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E-mail shown above. If you prefer, you can discuss your complaint in person or by phone. We are more than happy to try and resolve any concerns you may have. If you feel your concern was not handled in a satisfactory way, you may then file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights or the California Attorney General’s Office. We will not retaliate against you if you make a complaint.

Changes to This Notice: We reserve the right to change our privacy practices and to apply the revised practices 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. Notice Revised and Effective: April 27, 2020

Acknowledgment of receipt of practice policies and practices *
I have received this practices Notice of Privacy Practices written in plain language. The notice provides details of the uses and disclosures of my protected health information that may be used by this practice’s legal duties with respect to my information. I understand that this practice foresees the right to change the terms of its notice of Privacy Practices, and to make changes regarding all privileged health information resident at, or controlled by, this practice. I understand that I can obtain this practices current Notice of Privacy upon request.​​​​​​​

Subject*​​​​​​​
As part of your eye exam Austin Optometry Group recommends a special diagnostic procedure called Wellness Retinal Imaging. This procedure consists of capturing an image of the back part (retina) of your eye. This is not an x-ray or ultrasound procedure; and nothing will touch your eye. We are simply taking a digital photo.

This permanent record is very valuable in assessing the current health of your eye and for safeguarding the health of specific structures of your eye, such as the retina, optic nerve, macula, and blood vessels. It will also serve as an initial point from which to compare, as we follow your health in subsequent years.

Dr. Austin strongly recommends this procedure as part of your eye exam!

We recommend this procedure for every adult patient. To best care for our younger patients, we provide this service at no cost for children 12 and under.

The co-payment for this part of the eye exam is $34 per eye. Depending on your diagnosis, if pathology or an “at risk” condition is documented with the screening imaging, we will bill your health or medical insurance if we are on your plans. Otherwise we will provide you with a statement for you to file for reimbursement directly from your medical insurance.

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