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«Attleboro Vision Care Associates, P.C. 550 North Main Street Attleboro, MA 02703 (508) 222-9912 Dear New Patient: Welcome to Attleboro Vision Care ...»

Attleboro Vision Care Associates, P.C.

550 North Main Street Attleboro, MA 02703 (508) 222-9912

Dear New Patient:

Welcome to Attleboro Vision Care Associates, P.C.

Please complete the enclosed Patient Information Sheet and Medical Questionnaire using

black or blue ink, and bring them with you to your first appointment. This will speed up

the registration process for you.

If this is your first visit with us, please bring your glasses and/or contact lens boxes if possible, or your last written prescription. For existing contact lens wearers, please wear your contacts to your appointment.

Please note that Medicare and most major insurance carriers require physicians to obtain this medical information and retain it in their patients’ medical records. These documents will become part of your record.

Some insurance carriers only allow a routine eye exam every 24 months. Please note that you are responsible for checking with your insurance carrier to insure that you are eligible for your visit. This will help prevent delays at your appointment and insure you do not unexpectedly receive a bill for your visit. Also, authorization of insurance is not a guarantee of payment.

If you belong to a health plan that requires a referral for an eye exam, please contact your primary care physician to obtain one. Please note that the patient is responsible for obtaining a referral.

Again, we welcome you to Attleboro Vision Care Associates, P.C., and we look forward to meeting you and your family’s vision care needs.

Attleboro Vision Care Associates, P.C.

550 North Main Street Attleboro, MA 02703 (508) 222-9912 Welcome To Our Office Today’s Date: ___________

Patient Information:

Name: __________________________________________________________________________________

Last First Middle Address: ___________________________________ City________________ State______ Zip____________

Date of Birth:___________________ Sex:____ M____F Married____ Single_____ SS#: ________________

Home Phone: (_____)______________ Cell Phone: (_____)_____________ Email:_____________________

Occupation: ___________________________ Employer Name: ____________________________________

Employer Address: ______________________________________ Business Phone: (_____)_____________

Primary Care Physician: ____________________Location: __________________ Phone: (_____)_________ Emergency Contact Person/Phone Number ____________________________________________________

Guarantor Information: (Complete if patient is under 18 years of age) Name: __________________________________________________________________________________

Last First Middle Address: __________________________________ City: _______________ State: ______ Zip:___________ Home Phone: (_____)_____________ Cell Phone: (_____)______________ Email: ____________________

Business Phone:(_____)___________Date of Birth: ____________ Relationship to Patient: ______________

Insurance Information:

Please check if medical insurance is an HMO________ Medical Insurance Plan: __________________________________ Subscriber ID: _____________________

Vision Insurance Plan: ___________________________________ Subscriber ID: _____________________

Medicare No.______________________________ Medicaid No.____________________________________

Subscriber’s Name: __________________________________ Relationship to Patient: __________________

Subscriber’s Address: ______________________________________________________________________

(Complete if different from patient’s address) Subscriber’s SS#: ______________________________ Subscriber’s Date of Birth:______________________

Subscriber’s Employer: ___________________________Subscriber's Phone: (_____)___________________

Referral Information:

How were you referred to our practice?

____Friend/Relative ____Physician ____Optometrist ____Insurance Listing ____ Eye Screening Name of Referral Source: ______________________________

When was your last eye exam?______________

–  –  –

Payment Options:

-Cash, Check, all major credit cards or CareCredit healthcare credit card. (CareCredit is a healthcare credit card with special financing and payment options* for medical expenses.) Note: There is a $25 fee on all returned checks.

Please Note: A refraction is a measurement of the lens power necessary to prescribe glasses or other corrective lenses.

Most medical insurance plans, including Medicare, do not cover routine refractions or routine eye exams (when no medical eye problem is known or suspected). Medicare, and most other insurance plans, insists that we charge separately for that portion of the examination, since it is not a covered service. You will receive an explanation of benefits from them itemizing your responsibilities.

It is customary to pay for professional services when rendered. However, if you have a medical problem then we will bill your insurance on your behalf.** You are authorizing your insurance carrier to make payment directly to Attleboro Vision Care for any medical benefits due for services rendered and this is a direct assignment of your rights and benefits under this policy. You will be responsible for any co-payments, deductibles and/or non-covered services as determined by your insurance company. If you have a separate plan that covers routine examinations and/or glasses, please let us know. Your vision plan may assist you with your eye care needs that are not covered by your medical plan. We will bill your vision plan as above.** In accordance with our contract and with your insurance provider, we are responsible for collecting, and you are responsible for paying, co-payments at the time of service.


Please initial the following:

____ I authorize Attleboro Vision Care to release information to my insurance carrier to determine my benefits and I recognize and accept responsibility for any balance remaining after payment of such benefits.

____I understand that Attleboro Vision Care requires payment prior to products received/services rendered.

____I understand that I may be responsible for a contact lens exam fee $50-$150, dependent upon insurance.

____I am aware that I may be assessed a fee of $25 for canceling more than 3 times in a calendar year without a 24 hour notice.

____I understand that Attleboro Vision Care does not allow returns on prescription eye wear as they are made to order.

HMO Referral Waiver:

____I understand that it is my responsibility to obtain a referral from my primary care physician and that any charges incurred as a result of failing to do so are my responsibility.

For Medicare patients:

____I understand that I may be responsible for a refraction fee of $45, dependent upon supplemental insurance.

If you have any questions, please do not hesitate to ask.

–  –  –

*Subject to credit approval **However, if we do not receive payment from your insurance carrier within 30 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.


Name_____________________________________________ Date ________________________________

Date of Birth _____________________________________ Date of last eye exam ___________________

List any medications you currently take (Rx and over-the-counter): _____________________________________


Do you have allergies to any medications? YES NO If YES, list the medications:_____________________________________________________________________

List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.):


List any surgeries you have had (cataract, appendectomy): ____________________________________________

Do you currently have any problems in the following areas? If YES, please provide additional information.

Details YES NO EYES (poor vision, eye pain, tearing, redness, etc.) GENERAL / CONSTITUTIONAL (fever, heat stroke, weight loss, weight gain, unusually tired) EARS, NOSE, THROAT (hard of hearing, stuffy nose, earache, cough, dry mouth, etc.) CARDIOVASCULAR (high BP, racing pulse, etc.) RESPIRATORY (congestion, wheezing, short of breath, etc.) GASTROINTESTINAL (stomach upset, diarrhea, constipation, hernia, ulcers, etc.) GENITAL, KIDNEY, BLADDER (painful urination, frequent urination, impotence, yellow jaundice, etc.) FEMALES Are you pregnant? Nursing?

MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling, cramps, arthritis, etc.) SKIN (pimples, warts, growths, rash, etc.) NEUROLOGICAL (numbness, headache, seizures, paralysis, etc.) PSYCHIATRIC (anxiety, depression, insomnia) ENDOCRINE (diabetes, hypothyroid, etc.) BLOOD / LYMPH (bleeding, cholesterolemia, anemia, problems related to blood transfusion, etc.) ALLERGIC / IMMUNOLOGIC (sneezing, swelling, redness, itching, hives, lupus, etc.)

–  –  –

 I have received a copy of Attleboro Vision Care Associates, P.C.’s “Notice of Privacy Practices”.

 I understand that Attleboro Vision Care Associates, P.C. owns and maintains my Attleboro Vision Care Associates, P.C. medical records and, in its “Notice or Privacy Practices” has assured me that Attleboro Vision Care Associates, P.C. keeps information about me confidential as required by state and federal laws. I know that if I want to have access to my Attleboro Vision Care Associates, P.C. medical records or copies of any information in that record, I should ask anyone at Attleboro Vision Care Associates, P.C. for assistance.

–  –  –


This questionnaire was designed to assist your eye care professional in helping you select the perfect lenses, frames and/or contacts to suit your visual needs. Please take a moment to answer the following questions.

–  –  –

7. What do you like/dislike about your current glasses and/or contacts (comfort, style, fit, etc)?





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