Do you need to complete the check-in form you yourself only or do you need to also complete it for additional family members under 18 years of age? *
If you have multiple children under 18 coming under the same insurance plan, you may complete one form for all patients as the guarantor. However, if each child has individual insurance plans, you must complete a separate form per child.
Patient or Guarantor's Name *
The guarantor is always the patient unless the patient is an incapacitated adult or an unemancipated minor (under age 18), in which case, the guarantor is the patient's parent or legal guardian.
Do we already have your address and phone number on file? * Address
* If you're using insurance for this visit, do we already have your insurance information on file? * Please enter BOTH your medical and vision insurance information below. *
To add additional insurance, click on the + sign to the right of the field.
Hidden Do you want to provide your FSA/HSA or CC card information on this form?
To expedite your visit, you can enter the information for the card you want our office to keep on file for your visit charges and fees below. Your card will not be charged without your consent.
Hidden HSA/FSA or Credit Card Number
Please enter the information for the card you want our office to keep on file for your visit charges and fees below. Your card will not be charged without your consent
Please enter name and DOB for each patient
For additional patients, please click on the + sign in the right of the field to add more patients.
Ocular Symptoms *
To help our doctor provide the best care for you, please let us know if you are you currently experiencing or have experienced any of the following? Please select ALL that apply below or select NONE from list. After making selection, click the box again to select more options.
Blurry Vision Broken Glasses Burning Discharge Double Vision Dryness Excess Tearing/Watering Eye Infection/Red Eye/Pink Eye Eye Pain or Soreness Floaters or Spots in Vision Haloes Headaches None Itching Light Flashes Light Sensitivity Need New Contacts Redness Sandy/Dry/Gritty Feeling Tired Eyes Neck Pain Headaches Eye Strain Dizziness Discomfort with Computer Use Would you like to find out if your vitamins/supplements are providing the antioxidant defense network needed for optimal health in a toxic world? * Consents Notice of Privacy Practices * I have read or had explained to me Millennium Eye Center, Inc.’s Notice of Privacy Practices below and agree to continue my care with Millennium Eye Center, Inc. under said terms for myself and all minors listed above.
Millennium Eye Center Privacy/Security Official, James Justin
NOTICE OF PRIVACY PRACTICES - This notice was published and becomes effective on October 1, 2017
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
When it comes to your health
information, you have certain rights.
This section explains your rights and
some of our responsibilities to help you.
Get an electronic or paper copy of your
• You can ask to see or get an
electronic or paper copy of your
medical record and other health
information we have about you.
• We will provide a copy or a
summary of your health
information, upon your request,
within 30 days. We may charge a
reasonable, cost-based fee.
Ask us to correct your medical record:
• You can ask us to correct health
information about you that you
think is incorrect or incomplete.
• We are allowed by law to say “no”
to your request, but we’ll tell you
why in writing within 60 days.
Request confidential communications:
• You can ask us to contact you in a
specific way (for example, home
or office phone) or to send mail to
a different address.
• We will say “yes” to all reasonable
Ask us to limit what we use or share:
• You can ask us not to use or
share certain health information
for treatment, payment, or our
• We are not required to agree to
your request, and we may say
“no” if it would affect your care.
• If you pay for a service or health
care item out-of-pocket in full, you
can ask us not to share that
information for the purpose of
payment or our operations with
your health insurer.
• We will say “yes” unless a law
requires us to share that
Get a list of those with whom we’ve
• You can ask for a list (accounting)
of the times we’ve shared your
health information for six years
prior to the date you ask, who we
shared it with, and why.
• We will include all the disclosures
except for those about treatment,
payment, and health care
operations, and certain other
disclosures (such as any you
asked us to make). We’ll provide
one accounting a year for free but
will charge a reasonable, costbased
fee if you ask for another
one within 12 months.
Get a copy of this privacy notice:
• You can ask for a paper copy of
this notice at any time, even if you
have agreed to receive the notice
electronically. We will provide you
with a paper copy promptly.
Choose someone to act for you:
• If you have given someone
medical power of attorney or if
someone is your legal guardian,
that person can exercise your
rights and make choices about
your health information.
• We will make sure that person
has this authority and can act for
you before we take any action.
File a complaint if you feel your rights
• You can complain if you feel we
have violated your rights by
contacting us using the
information on page 1.
• You can file a complaint with the
U.S. Department of Health and
Human Services Office for Civil
Rights by sending a letter to 200
Independence Ave., S.W.,
Washington, D.C. 20201, or by
calling 1-877-696-6775, or by
• We will not retaliate against you
for filing a complaint.
For certain health information, you can
tell us your choices about what we
share. If you have a clear preference
for how we share your information in
the situations described below, talk to
us. Tell us what you want us to do, and
we will do our best to follow your
In these cases, you have both the right
and choice to tell us to:
• Share information with your family,
close friends, or others involved in
• Share information in a disaster relief
• Contact you for fundraising efforts.
• If you are not able to tell us your
preference, for example if you are
unconscious, we may go ahead and
share your information if we believe
it is in your best interest. We may
also share your information when
needed to lessen a serious and
imminent threat to health or safety.
In these cases we NEVER share your
information UNLESS you give us
• Marketing purposes.
• Sale of your information.
In the case of fundraising:
• We may contact you for fundraising
efforts, but you can tell us not to
contact you again.
OUR USES AND DISCLOSURES:
How do we typically use or share your
health information? We typically use or
share your health information in the
• We can use your health
information and share it with other
professionals who are treating
• For example, a doctor treating you
for an injury asks another doctor
about your overall health
Run our organization:
• We can use and share your health
information to run our practice,
improve your care, and contact
you when necessary.
• For example, we use health
information about you to manage
your treatment and services.
Bill for your services:
• We can use and share your health
information to bill and get payment
from health plans or other entities.
• For example, we give information
about you to your health insurance
plan so it will pay for your services.
How else can we use or share your
health information? We are allowed or
required to share your information in
other ways – usually in ways that
contribute to the public good, such as
public health and research. We have to
meet many conditions in the law before
we can share your information for these
purposes. For more information see
Help with public health and safety
• We can share health information
about you for certain situations such
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to
• Reporting suspected abuse, neglect,
or domestic violence
• Preventing or reducing a serious
threat to anyone’s health or safety
• We can use or share your
information for health research.
Comply with the law.
• We will share information about you
if state or federal law requires it,
including with the Department of
Health and Human Services if it
wants to see that we’re complying
with federal privacy law.
Respond to organ and tissue donation
We can share health information about
you with organ procurement
Work with a medical examiner or
We can share health information with a
coroner, medical examiner, or funeral
director when an individual dies.
Address workers’ compensation, law
enforcement, and other government
• We can use or share health
information about you:
• For workers’ compensation claims
• For law enforcement purposes or
with a law enforcement official
• With health oversight agencies for
activities authorized by law
• For special government functions
such as military, national security
and presidential protective services.
Respond to lawsuits and legal actions:
• We can share health information
about you in response to a court or
administrative order, or in response
to a subpoena.
• Our practice does not create or
manage a hospital directory, nor do
we have or maintain psychotherapy
notes at this practice.
• We adhere to all FLORIDA laws that
require greater limits on disclosures
than the federal HIPAA/HITECH
We are required by law to maintain the
privacy and security of your protected
We will let you know promptly if a
breach occurs that may have
compromised the privacy or security of
We must follow the duties and privacy
practices described in this notice and
give you a copy of it.
We will not use or share your
information other than as described
here unless you tell us we can in
writing. If you tell us we can, you may
change your mind at any time. Let us
know in writing if you change your
For more information see:
CHANGES TO THE TERMS OF THIS
We can change the terms of this notice at
any time, and the changes will apply to all
information we have about you. The new
notice will be available upon request, in our
office, and on our website. Payment, Fees & Refund Policies * I consent to MEC's payment, fees & refund policies for myself and all the minors listed above..
Payment is expected at Time of Service
For all patients, payment of insurance co-pays, deductibles, and services not covered by insurance are to be paid for at the time the service is rendered.
There will be a $5 billing fee charge to cover our administrative mailing costs if payment is not made at the time of service. Also, anyone submitting insurance paperwork after the original date of service will be charged a fee of $5.
You are responsible for any balances not covered by your insurance, including rejected claims. While every effort will be made to submit claims in accordance with insurers' requirements for payment, in the event of a dispute or rejection, you as the insured or guarantor are responsible for payment.
Insurance claims not paid within 90 days after the original date of service will become the responsibility of the patient/insured.
For the purpose of this agreement, “non covered charges” are charges otherwise billed, that are not covered by a third party for any reason. These charges may include, but are not limited to: denial of coverage, exclusion of coverage and absence of a responsible third party payer. However, “non covered charges” do not included differences between MEC charges and rates that have been established through contract, if applicable. Regardless of my status at the time I sign this agreement. Whether I am signing as an agent/representative or patient, I obligate myself to this agreement which states that payment of services rendered will be paid to MEC regardless of condition. I hereby guarantee payment of all applicable co- payments, deductibles, and charges not covered through benefits. In the event any portion of said patient’s account(s) are referred to an attorney for collection due to non payment, I agree to payment of all expenses pertaining to collection, including reasonable legal fees regardless if suit is filed or is not filed.
My consent on this page indicate that I agree that Millennium Eye Center (MEC) will receive payment for all services rendered, at the time they are rendered. Payment of services includes but is not limited to all co payments, deductibles and charges not covered by third party payers. I further understand that in the event that benefits are not verifiable, that I will be responsible for all charges estimated for services rendered for myself and all minors listed above.
PAYMENT RESPONSIBILITY FOR DIVORCED/SEPARATED PARENTS
The person who brought the child in for services is responsible for payment. This office cannot be responsible for collecting from any other individual.
• Cancellation fee for all orders is $50
• Returned check fee is $40
• All coupons must be presented at time of service
• Payment responsibility for missed appointments $50 fee
o To avoid this fee a 24 hour notice is required
o This payment is the responsibility of the patient: insurers do not cover this fee
• There are NO REFUNDS on professional services.
• There are NO REFUNDS of payments for materials once an order is processed.
• For Glasses:
o If patient is on a payment plan, follow the rules of that payment plan for refund of unprocessed orders.
• For Contacts:
o There are NO REFUNDS of professional exam fees.
o NO REFUND on materials once contacts are dispensed.
o However, we can do a one-time complimentary exchange of the unused contact lenses purchased from us. Boxes must be resalable, meaning – there should be no marks or writing, no torn or missing labels on boxes and each box must be factory sealed.
There is a $20 processing fee for all exchanges. Do you consent to electronically sign this form? *
If you intend to electronically sign the following form, please read this carefully before signing. By typing your name electronically on the field below, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this check-in Form. You will receive a copy of this form after it has been submitted. If you do not consent to electronic signature, you will need to print the signature form on the next page, sign it then email a copy to email@example.com. The check-in process will not be complete until we receive the signature form.