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«Name: First Middle Last Address: Street or P.O. Box City State Zip County: Birth Date: _/_/_ Age: Month / Day / Year Telephone: _ Home # Work # ...»

Frank Haskell Lions Eye Clinic • Lighthouse Mission Ministries

P.O. Box 548 Bellingham, WA 98227; 1013 W. Holly St. Bellingham, WA; 360-756-6128


Today’s Date: _____________________________



First Middle Last



Street or P.O. Box City State Zip County: ____________________________ Birth Date: _____/_____/_____ Age: ______________

Month / Day / Year Telephone: _______________________________________________________________________

Home # Work # Message or Cell # May we leave a message? Yes No If so, which number? ______________________________

Email: ____________________________________________________________________________________

Employment Status: Sex: Marital Status:

Full Time Self-employed M Single Part Time Retired F Married Temporary Unemployed Divorced Do you have insurance or medical coupons? Yes No Medicaid: Yes No Medicare: Yes No Other:_____________________

Do you have any other vision insurance? Yes No Name of Employer (For Statistical Purposes Only) ______________________________________

Current Occupation: _________________________________ Years: _________ Do you have dependent children living with you? If so, how many? __________ Yes No Total Number of People in Household, Counting Yourself : __________________

US Citizen: Primary Language:

Yes No English Other__________________

Monthly Household Income: $___________ Source of Income (check all that apply):

Salary/Wages Unemployment Disability (Before Taxes) Social Security Retirement Pension Worker’s Compensation Other __________ What is your housing situation?

Own Rent Staying with family/friends Homeless Other ______________________

–  –  –

I, _________________________________________________, (Patient name or legally responsible person) hereby grant permission to the staff and professional volunteers of the Frank Haskell Lions Eye Clinic and the Lighthouse Mission Ministries to employ such established treatment and therapy as deemed professionally necessary or advisable in the diagnosis and treatment of any/all vision impairment/eye disease. I understand that a licensed Optometric Physician will provide the diagnosis and treatment.

Treatment plan options, alternatives and potential negative consequences have/will be explained to me.

I have or will have the opportunity to ask questions about my treatment plan(s) and these questions have or will be answered to my satisfaction. I believe that I understand both the benefits and potential serious risks associated with the treatment plan(s) proposed to me and I understand that I may refuse any part of the proposed treatment. If I consent to treatment, I acknowledge that no warrantee or guarantee has been made to me regarding the result or cure.

I further authorize the Frank Haskell Lions Eye Clinic and Lighthouse Mission Ministries to collect medical information and release medical information to persons or agencies directly concerned with public health or community welfare and to private individuals professionally engaged in carrying out a treatment plan.

I hold harmless all personnel and volunteers associated in any way with the Frank Haskell Lions Eye Clinic and the Lighthouse Mission Ministries for any and all types of treatment that I have consented to receive.

I certify that this form has been fully explained to me, that I have read it, or have had it read to me, and that I understand its contents.

Patient (or guardian) Signature: ______________________________ Date: ______________

Relationship to Patient (if guardian): ______________________________________________

–  –  –





We respect our legal obligation to keep health information that identifies you private.

We are obligated by law to give notice of our privacy practices. Generally, we cannot use or disclose your health information outside of our office without your written permission. In some limited situations, the law allows or requires us to disclose your health information without either a written consent or authorization.


We will ask you to sign Consent to Treatment Form allowing us to use and disclose your health information for purposes of treatment and health care operations of this office. We are allowed to refuse to treat you if you do not sign the consent form.

We use information for treatment purposes, when, for example, when our volunteer doctor tests your eyes, when the doctor prescribes glasses or contact lenses, when you doctor prescribes medication, when our staff helps you select and order glasses or contact lenses, and when we show you low vision aids.

We may disclose your health information outside of our office for treatment purposes if we, for example, refer you to another doctor or clinic for eye care or low vision aids or services, if we send a prescription for glasses or contacts to another to be filled, when we provide a prescription for medication to a pharmacist, or when we phone to let you know that your glasses or contact lenses are ready to be picked up. Sometimes we may ask for copies of your health information from another professional that you may have seen before us.

We use and disclose your health information for health care operations in a number of ways. Health care operations mean those administrative and managerial functions that we have to do in order to run our office.

We may use or disclose your health information, for example, for internal quality assurance, for personnel decisions, and for outside storage of our records.


In some limited situations, the law allows or requires us to use or disclose your health information without your permission. 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 purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the Food and Drug Administration regarding drugs or medical devices;

• Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence;

• 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;

• Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;

• Uses and disclosures to prevent a serious threat to health or safety;

–  –  –


The law gives you many rights regarding your health information. You can:

• Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment) or health care operation. We do not have to agree to do this, but if we agree, we must honor the restriction that you want.

• Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using email to your personal e-mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost.

• Ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us. You may have to pay for photocopies in advance.

If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally required. By law, we can have one 30-day extension of the time for us to give you access or photocopies if we send you a written notice.

• Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension.

• Get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want), except disclosures for purposes of treatment or health care operations and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-days extension for time if we notify you of the extension in writing.


By law, we must abide by terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time in compliance with and as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice for Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web Site.

COMPLAINTS If you think what we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human services, Office for Civil Rights.


If you want more information about our privacy practices, call or visit the Olympia Union Gospel Mission Community Vision Clinic at the address or phone number shown at the beginning of the form.

I certify that this form has been fully explained to me, that I have read it, or have had it read to me, and that I understand its contents.

Patient (or guardian) Signature: ______________________________ Date: __________ Relationship to Patient: _____________________________________

–  –  –

Name: _____________________________________________ Date: _______________________





–  –  –

Are you a resident of Lighthouse Mission: Yes No Are you a Whatcom County resident: Yes No If yes, how long?__________________________

–  –  –

Total number living in household (including self):__________

Household Monthly Income:


–  –  –

TOTAL INCOME: $_________________

Do you have a case manager: Yes No If yes, which agency?_____________________________

Case managers name:_____________________________ phone:________________________

–  –  –

Name: _____________________________________________ Date: _______________________


What is the main reason for today’s exam? ________________________________________________

When was your last exam? _____________________________________________________________

Current Occupation: __________________ Years: _________ Employer:_______________________

–  –  –

Past Illnesses, Injuries, or Surgeries: ___________________________________________________________

Current Medications: _______________________________________________________________________

Have you been prescribed medications that you do not use?


Medicines that cause reactions or sensitivities?


Specific Allergies: __________________________________________________________________________

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