Welcome to Blount County Eye Center!
uName: ____________________________________
uDate of Birth: _____/_____/_____ uAge: ______
uSocial Security: ______-______-______
uName You Go By: __________________________
1. Your Basi c Informa tion
u Home Address: ___________________________________________________ Apt. #: __________
u City: _____________________ u State: ___________________ u Zip Code: ________________
u Phone: (_____)_____-________ Cell / Home / Work u Alternate Phone : (_____)_____-________
u Email: __________________________________________________________________________________
u Sex: Male / Female / Other v Mari tal Status: Single / Married / Divorced / Widowed / Other
v Are You Currently: Employed / Student / Retired / Disabled / Not Employed / Other
u Occupation: ___________________________ u Employer/School: ___________________________
v Race : American Indian or Alaskan Native / Asian / African American / Hispanic / White (Hispanic)
White (Not Hispanic or Latino) / Native Hawaiian/Other Pacific Islander / Other: ________________
u Medical Insurance: ________________________________________
Self / Spouse / Parent / Other
u Secondary Medica l Insurance: ____________________________
Self / Spouse / Parent / Other
u Vision Benefit Plan: _______________________________________
Self / Spouse / Parent / Other
2. Contact Preferences
Please select the ways in which you would like Blount County Eye Center to attempt to contact you for
appointment reminders, questions on your account, job status, etc.:
Phone || Email || Ma il || Text
3. Other Information About You
u H ow D id Yo u H ear Abou t Us: ___________________________________________________________________________
u Pr imary C are Ph ys ic ian: ________________________________ v Las t Ex am: _________________________
v Pr efe rre d Ph armac y an d Lo cati on: ______________________________________________________________________
u Las t Ey e Ex am: ____________________________ u W he re ? __________________________________
u Do You W ear Gl asse s? Yes / No
v If so , Are You Ha ppy w ith Th e m? Yes / No
u Do You W ear Co nta ct L en se s? Yes / No
v If so , Are You Ha ppy w ith Th e m? Yes / No
u Are Yo u I nt ere st ed I n: Glasses / Contact Lenses / LASIK / Other: ____________________________________________
Copy of current Medical Insurance card
Copy of current Vision Benefit Plan benefits/authorization
Copy of signed BCEC Practice Policies/HIPPA
Copy of signed Refraction ABN (new at each exam if applicable)
Copy of referral (if required)
If all of th e in form a tion listed is a ccura te, p lea se sig n b elow a nd th ank you for ch oosing B CEC!
Signature: _______________________________________________________ Date: _____/_____/_____
Medical and Eye Health History
Patient Name: ________________________________
ID#: ___________________ DOB: _____/_____/_____
Eye Health History
Please indicate which of the following you are either currently experiences or have experienced in the past:
Ÿ Red/Bloodshot Eyes Current / Past / Never
Ÿ Blurred Vision
Current / Past / Never
Ÿ Burning Eyes
Current / Past / Never
Ÿ Cataracts
Current / Past / Never
Ÿ Poor Color Vision
Current / Past / Never
Ÿ Crossed/Lazy Eye
Current / Past / Never
Ÿ Eye Discharge
Current / Past / Never
Ÿ Double Vision
Current / Past / Never
Ÿ Dry Eyes
Current / Past / Never
Ÿ Eye Infection
Current / Past / Never
Ÿ Eye Injury
Current / Past / Never
Ÿ Eye Strain
Current / Past / Never
Ÿ Fainting/Blackouts
Current / Past / Never
Ÿ Floaters/Spots
Current / Past / Never
Ÿ Glaucoma
Current / Past / Never
Ÿ Itching Eyes
Current / Past / Never
Ÿ Light Sensitivity
Current / Past / Never
Ÿ Migraine/Headaches Current / Past / Never
Ÿ Loss of Vision
Current / Past / Never
Ÿ Seeing Halos
Current / Past / Never
Ÿ Seeing Flashes
Current / Past / Never
Ÿ Twitching Eyelids
Current / Past / Never
Ÿ Watering Eyes
Current / Past / Never
Ÿ Glare
Current / Past / Never
Ÿ Cornea Disease
Current / Past / Never
Ÿ Macular Disease
Current / Past / Never
Ÿ Retina Disease
Current / Past / Never
Ÿ Retinal Detachment
Current / Past / Never
Ÿ Diabetic Retinopathy Current / Past / Never
Known Eye Disorders: ___________________________________________________________________
Eye Surgeries/Injuries in Past: ____________________________________________________________
Any Type of Eye Drops Used: _____________________________________________________________
Family History of Eye Disease: Yes / No / Unknown
Disease: ___________________________
Relation to You: ____________________
Disease: ___________________________
Relation to You: ____________________
Disease: ___________________________
Relation to You: ____________________
Disease: ___________________________
Relation to You: ____________________
Medical History
Please indicate which of the following you suffer from and indicate if a known family member does as well:
Ÿ Arthritis
Yes / No / Family
Ÿ Rheumatoid Arthritis Yes / No / Family
Ÿ High Blood Pressure Yes / No / Family
Ÿ Heart Disease
Yes / No / Family
Ÿ Thyroid Disease
Yes / No / Family
Ÿ Diabetes
Yes / No / Family
Ÿ High Cholesterol
Yes / No / Family
Ÿ Asthma
Yes / No / Family
Ÿ Skin Cancer
Yes / No / Family
Ÿ Anxiety/Depression
Yes / No / Family
Ÿ Lupus
Yes / No / Family
Ÿ Anemia
Yes / No / Family
Known Medical Issues: __________________________________________________________________
______________________________________________________________________________________
Medications and Allergies
Please list all medications you currently take or indicate if you’ve provided a current list today:
1. ________________________________________ 5. _________________________________________
2. ________________________________________ 6. _________________________________________
3. ________________________________________ 7. _________________________________________
4. ________________________________________ 8. _________________________________________
Known Medication Allergies? _____________________________________________________________
Social History and Information Required by Insurance
Do you drink alcohol?
Yes / No
If yes, how much? __________________________
Do you smoke?
Yes / No
If yes, how much? ________________ How long? ________
Are you a former smoker? Yes / No
Height: ___________
Weight: ____________
History of Blood Transfusion?____________________
QUALITY OF LIFE SYMPTOM CHECKLIST*
Check the column that best represents
Patient's Name: ________________________________
the occurrence of each symptom.
Date: _________________________________________
0
Never
1
Seldom
2
Occasionally
3
Frequently
4
Always
1 Blur when looking at near
2 Double vision
3 Headaches with near work
4 Words run together when reading
5 Burning, itchy, watery eyes
6 Falls asleep reading
7 Sees worse at the end of the day
8 Skips/repeats lines when reading
9 Dizziness/nausea with near work
10 Head tilt/closing one eye when reading
11 Difficulty copying from chalkboard
12 Avoids near work/reading
13 Omits small words when reading
14 Writes uphill/downhill
15 Misaligns digits/columns of numbers
16 Reading comprehension down
17 Poor/inconsistent in sports
18 Holds reading too close
19 Trouble keeping attention on reading
20 Difficulty completing assignments on time
21 Always says "I can't" before trying
22 Avoids sports/games
23 Poor hand-eye (poor handwriting)
24 Does not judge distance accurately
25 Clumsy, knocks things over
26 Does not use his/her time well
27 Does not make change well
28 Loses belongings/things
29 Car/motion sickness
30 Forgetful/poor memory
TOTAL
Add up the total points: Below 15 routine eye care exam; 16-24 visual functional problem referral needed to a
developmental optometrist; >25 refer for developmental vision evaluation.
*Checklist is from the College of Optometrists in Vision Development www.covd.org
Maryville, TN | P: 865-­‐982-­‐6761 | F: 865-­‐982-­‐7402 | www.blounteye.com Optometric Physicians :: Lloyd Tantum, OD | William Tantum, OD | Susan Carter, OD | Cassie Bruno, OD Ophthalmologists :: Thomas Browning, MD | Matthew Lowrance, DO Office Contact Person: Dr. William Tantum
Blount County Eye Center
702 S. Foothills Plaza Dr.
Maryville, TN 37801
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.
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our
privacy practices. This notice describes how we protect your health information and what rights you have regarding it.
TREATEMENT, PAYMENT AND HEALTH CARE OPERATIONS
The most common reasons why we use or disclose your health information is for treatment, payment or health care operations.
Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you, testing or examining
your eyes; prescribing glasses, contact lenses or eye medications and faxing them to be filled, showing you low vision aids; referring
you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another
professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are:
asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting
unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and
managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for
health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care
plans; defense of legal matters; business planning; and outside storage of our records.
We routinely use your health information inside our office for these purposes without any special permission. If we need to
disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.
We will ask for special written permission in the certain situations.
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
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
federal Food and Drug Administration regarding drugs or medical devices;
disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
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 suspected to be a victim in 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 or disclosures for health related research;
uses or disclosures to prevent a serious threat to health or safety;
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 members
of the foreign service;
disclosures of de-identified information;
disclosures relating 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 or disclosures;
disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your
health information;
Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your eye
care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments or that it is time to make a routine appointment. We may also
call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise we will
Maryville, TN | P: 865-­‐982-­‐6761 | F: 865-­‐982-­‐7402 | www.blounteye.com Optometric Physicians :: Lloyd Tantum, OD | William Tantum, OD | Susan Carter, OD | Cassie Bruno, OD Ophthalmologists :: Thomas Browning, MD | Matthew Lowrance, DO mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with
someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written “authorization form”. The
content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or
disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for use to send your information to someone else.
Typically, in this situation you will give a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the
authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in
reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
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), payment of health care
operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a
restriction, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
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 email address. We will accommodate these requests if
they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written
request to the office contact person at the address, fax or email at the beginning of this Notice.
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 to have a copy of your health information
within 30 days of asking us (or sixty days if the information is stored off-site). 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 available. 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 of the extension. If you want to review or get photocopies of your health
information, send a written request to the office contact person at the address, fax or email shown at the beginning of this
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 in 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. If you want to ask us to amend your health information, send a written request,
including your reasons for amendment, to the office contact person at the address, fax or email shown at the beginning of this
Notice.
get a list of the disclosures that we have made of your health information with the past 6 years (or shorter period if you want).
By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your
authorization; incidental disclosures; disclosures required by law; 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 day extension of time if we notify you of
the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or email
shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to
change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health
informations that we already have as well as to such information that we may generate in the future. If we change our Notice of
Privacy Practices, we will post the new notice in our office, have copies available in our office and post it on our website.
COMPLAINTS
If you think that 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 Humans Services, Office for Civil Rights. We will not retaliate against you if you make a complaint.
If you want to complain to us, send a written complaint to the office contact person at the address, fax or email shown at the
beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the address or phone number
shown at the beginning of this Notice.
Practice Policy Agreement
Patient Name: __________________________________
ID#: ____________________ DOB: _____/_____/_____
v Payment & Refund Policy
I understand that all fees for products and/or services not covered by insurance and co-pays are due
at the time of service. I understand that any balances not covered by my insurance will be my responsibility.
Orders for eyewear products cannot be placed until payment is made. Professional fees for exams cannot
be refunded once performed. Product refunds over $25 must be processed and will be issued by check. In
the event of returned eyewear there may be frame restocking fees and customized lens return fees. By
signing below I acknowledge acceptance of these policies.
Initials: _________
v Authorization for Insurance Payments
We request your signature on file in the event the office files insurance for you. This clause applies to
all insurance and vision benefit carriers. This signature will serve as authorization for the lifetime of the
patient for which it is on file.
I request that payment of authorized carrier of Medicare benefits be made either to me or on my
behalf to Blount County Eye Center for any services furnished me by this/these doctors. I authorize any
holder of medical information about me to be released to the Centers for Medicare and Medicaid Services
and its agents any information needed to determine these benefits or the benefits payable for related
services.
Initials: _________
v Notice of Privacy Practices Acknowledgement
I have had the opportunity to receive a copy of this practice’s Notice of Privacy Practices. The notice
provides the uses and disclosures of my protected health information that may be made by this practice,
my individual rights, how I may exercise those rights, and the practice’s legal duties with respect to my
protected health information. I understand that the practice may change the terms of its Notice of Privacy
Practices and that any changes apply retroactively to information created while the current notice is in
effect. I understand I can obtain this practice’s current Notice of Privacy Practices upon request.
Initials: _________
v Vision vs. Medical Eye Health Exams
Both vision plans and medical insurances cannot be billed on the same date of service without risk of
denial and balances being transferred to patients. Our physicians will address the most pressing eye health
issue and bill appropriately, but this may require multiple visits to completely care for your eye health care
needs. You will be informed when this is the case.
Initials: _________
Sign Here: ________________________________________________ Date: _____/_____/_____
Please
Relationship to patient if guardian: _____________________________________