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New Patient Form

Medical History

  • Please let us know who (first and last name) referred you to us. If nobody referred you to us, please type "NA."
  • Check all that apply to YOUR HISTORY
  • Check all that apply to your FAMILY HISTORY

  • Patient Financial Policy

    We hope that you will recognize that our financial policy is a necessary part of assuring the resources required to maintain this health care service for our patients and for the community
  • If we are in-network for your insurance carrier:
  • In order to bill your insurance company for your health care costs, it is extremely important that we obtain complete information about your medical and vision insurance companies, including phone numbers, addresses, a copy of your insurance card, and photo identification. If this information is not provided, you will be required to pay any charges in full at the time of service. Even though we bill your insurance company for you, we still collect the office visit co-pay, deductible, and co-insurance at the time of service. Some services may be deemed non-covered or not medically necessary by your insurance company, if so you are directly responsible for the charges incurred.
  • If we are out-of-network for your insurance carrier
  • We require that all services and materials be paid in full at the time of service. We will assist you in submitting your claim by providing you with a detailed billing statement of your charges, which you may forward to your insurance carrier.
    • We accept Cash and all major credit cards: Visa, MasterCard, American Express, and Discover.
    • We also accept personal checks with the proper identification.
    o We use an electronic checking system, which automatically withdraws the amount from your checking account, much like a debit card. If you request that we do not run your check electronically we will be more than happy to do so; however, there will be a $30 NSF fee for any returned checks.
    When your bill is unpaid, a collection agency may be chosen to manage delinquent accounts. If your account is placed with an agency, you will be assessed a 25% surcharge. The patient is solely responsible for all costs of collections.
  • I have read and fully understand my financial responsibilities under this policy.
  • Date Format: MM slash DD slash YYYY
  • I acknowledge that I have read and fully understand the HIPAA privacy form provided to me by TrueVision Eyecare.
  • Date Format: MM slash DD slash YYYY
  • Thank you for choosing TrueVision Eyecare as your vision care providers.

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