Salt Lake Eye Associates (801) 281-2020
Patient Information Sheet
Social Security #
Date of Birth
Name of Spouse
Primary Insurance Company
(Vision Correction/Special Lens)
Signature (sign in office)
Parents or Responsible Party if Different from Patient
Work or Cell Phone
Social Security #
Family Doctor Name
Reason for eye visit today
REVIEW OF SYSTEMS
Do you have any problems in the following areas? Please click on those that apply.
Weight Loss or Gain
Loss of vision
Sandy or gritty feeling
Foreign body sensation
Eye pain or soreness
Chronic infection of eye or lid
High blood pressure
ENT (ear, nose, throat, mouth)
Head allergy symptoms
Hay fever symptoms
Irregular heart beat
Family History (grandparents, parents, siblings):
Please check on those that apply and state the relationship
High blood pressure
Relationship to Patient
Do you drive?
Do you have visual difficulty when driving?
Do you have problems with night vision?
Have you ever tried to wear contacts?
Do you wear contact lenses? If yes, what kind?
Do you currently wear glasses?
If yes, how long have you had the current pair?
Do you drink alcohol?
Do you smoke?
History reviewed: No changes Additions as noted above
List any medications you take
List all allergic reactions to medications
List all major illnesses and injuries
List any surgeries you have had
Have you had crossed eyes, lazy eye, drooping eyelid, prominent eyes, or any eye surgery?
Salt Lake Eye Associates
1025 East 3300 South #B
Salt Lake City, Utah 84106
LIFETIME SIGNATURE AUTHORIZATION
I UNDERSTAND THAT I AM RESPONSIBLE FOR MY BILL EVEN IN THE EVENT MY INSURANCE DENIES EITHER PART OR ALL OF MY CLAIM.
I UNDERSTAND THAT IF MY INSURANCE COMPANY REQUIRES A REFERRAL BEFORE SERVICES ARE PERFORMED AND IF I DO NOT PROVIDE THAT REFERRAL I AM RESPONSIBLE TO PAY FOR SERVICES.
I AUTHORIZE DIRECT PAYMENT BY INSURANCE COMPANIES TO MY PHYSICIAN AND I RELEASE ANY INFORMATION ACQUIRED IN THE COURSE OF MY EXAMINATION FOR TREATMENT TO THOSE INSURANCE COMPANIES.
I FURTHER REQUEST THAT ANY SUPPLEMENTAL INSURANCE BENEFITS FILED IN MY BEHALF BE PAID AS STATED ABOVE.
I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION (HCFA) AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.
I UNDERSTAND THAT SERVICE CHARGES ARE ASSESSED AT 1.5% PER MONTH, WITH A MINIMUM CHARGE OF $5.00 ON BALANCES 30 DAYS AND OLDER. I AGREE TO PAY ALL INTEREST CHARGES, COLLECTION FEES, AND/OR ATTORNEY’S FEES OR COURT COSTS IF ANY DELINQUENT BALANCE IS PLACED WITH A COLLECTION AGENCY OR ATTORNEY FOR
COLLECTION OR SUIT.
I UNDERSTAND THAT CO-PAYS ARE DUE THE DAY OF SERVICE. IF I AM BILLED FOR MY CO-PAY THERE WILL BE AN ADDITIONAL $10.00 CHARGE ADDED TO MY BILL.
I UNDERSTAND THAT MY EYES MAY BE DILATED IN THE COURSE OF MY EXAM AND THAT AS A CONSEQUENCE I MAY EXPERIENCE TRANSIENT BLURRING OF VISION WHICH MY MAKE IT DIFFICULT FOR ME TO DRIVE, READ, OR CARRY ON NORMAL VISUAL ACTIVITIES UNTIL THE EFFECT WEARS OFF OR IS REVERSED. ALLERGIC REACTIONS TO THE MEDICATIONS ARE VERY RARE. DARK GLASSES WILL BE PROVIDED AT THE END OF THE VISIT TO PROVIDE COMFORT IN BRIGHT LIGHT. YOU MAY ASK EITHER THE TECHNICIAN OR PHYSICIAN NOT TO DILATE YOUR EYES.
I UNDERSTAND THAT MEDICARE AND MEDICAID DO NOT PAY FOR THE REFRACTION (GLASSES PRESCRIPTION) AND THAT IF THIS SERVICE IS PROVIDED I WILL BE RESPONSIBLE FOR PAYMENT
OF THIS SERVICE.
Signature (sign in office)
PATIENT CONSENT FORM
The Department of Health and Human Services has established a “Privacy Rule” to
insure that personal health care information is protected for privacy. The “Privacy Rule” was
also created in order to provide a standard for certain health care providers to obtain their
patients’ consent for uses and disclosures of health information about the patient to carry out
treatment, payment, or health care operations.
As our patient we want you to know that we respect the privacy of your personal
medical records and will do all we can to secure and protect that privacy. We strive to
always take reasonable precautions to protect your privacy. When it is appropriate and
necessary, we provide the minimum necessary information to only those we feel are in
need of your health care information and information about treatment, payment, or health
care operation in order to provide health care that is in you best interest.
We also want you to know that we support your full access to your personal medical
records. We may have indirect treatment relationships with (such as laboratories that only
interact with physicians and not patients) and may have to disclose personal health
information for purposes of treatment, payment, or health care operations. These entities
are most often not required to obtain patient consent.
As part of our treatment program you will be sent post cards that will remind you that
it is time to make an appointment. In addition, as a courtesy to our patients we will call to
confirm appointments. We will leave messages if we are not able to contact you directly.
You may refuse to consent to the use of disclosure of your personal health information but
this must be in writing. Under this law, we have the right to refuse to treat you should you
choose to refuse to disclose your Personal Health Information (PHI). If you choose to give
consent in this document at some future time you may request to refuse all or part of you
PHI. You may not revoke actions that have already been taken which relied on this or a
previously signed consent.
If you have any objections to this form, please ask to speak with our HIPAA
You have he right to review our privacy notice, to request restrictions and revoke
consent in writing after you reviewed our privacy notice.
Signature (sign in office)
COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS
To Our Valued Patients:
The misuse of Personal Health Information (PHI) has been identified as a national
problem causing patients inconvenience aggravation, and money. we want you to know
that all of our employees, managers, and doctors continually undergo training so that they
may understand and comply with government rules and regulations regarding the Health
Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the
“Privacy Rule.” We strive to achieve the very highest standards of ethics and integrity in
performing services for our patients.l
It is our policy to properly determine appropriate use of PHI in accordance with the
governmental rules, laws, and regulations. We want to ensure that our practice never
contributes in any way to the growing problem of improper disclosure of PHI. As part of
this plan, we have implemented a Compliance Program that we believe will help us
prevent any inappropriate use of PHI.
We also know that we are not perfect! Because of this fact, our policy is to listen to
our employees and our patients without any thought of penalization if they feel that an
event in any way compromises our policy of integrity. More so, we welcome your input
regarding any service problem so that we may remedy the situation promptly.
Thank you for being one of our highly valued patients.
Print name (Fill in at office)
give my permission for Salt Lake Eye Associates to discuss my health information, treatment, or billing information with the following individuals
Signature (sign in office)
RACHEL S. BENATOR, MD
1025 E 3300 S
SALT LAKE CITY, UTAH 84106
CONTACT LENS POLICY
A. I’ve never worn contact lenses before or I haven’t been wearing
1. Your initial prescription for contacts will be fitted and filled at Clair Optical.
The fitting fee is $50.00 and billed by Salt Lake Eye Associates, LLC.
2. If you decide to get your contacts elsewhere, you may do so. This office will
provide your glasses prescription and corneal readings only. You will then
need to pay for your contact lens fitting at the location of your choice.
B. I currently wear contacts, but my prescription is changing.
1. The re-fitting fee for a change in contacts when fit at Clair Optical is $25.00.
After your initial re-fit, you may purchase refills at the location of your choice.
2. If you choose to get your contacts elsewhere, we will provide your glasses
prescription and corneal readings. You will need to pay for a fitting at
the location of your choice.
C. I currently wear contacts and they do not need to be changed.
1. If you supply us with the brand, base curve, and power of the contacts desired
and the doctor agrees with the prescription, we will write out your contact lens
prescription so that you may get refills. You will need to sign a release. A basic
contact lens evaluation is $20.00 and billed by Salt Lake Eye Associates, LLC.
2. If you have previously purchased your contacts at Clair Optical, your contact
information is on file and you may return there for refills.
I have read and agree to the above.
Signature (sign in office)
ARTICLE 1 DISPUTE RESOLUTION
By signing this Agreement ("Agreement") we are agreeing to resolve any Claim for medical malpractice by the dispute resolution process described in this Agreement. Under this Agreement, you can pursue your Claim and seek damages, but you are waiving your right to have it decided by a judge or jury.
ARTICLE 2 DEFINITIONS
A. The term "we," "parties" or "us" mean you, (the Patient), and the Provider.
B. The term "Claim" mean one or more Malpractice Actions defined in the Utah Health Care Malpractice Act (Utah Code 78-14-3(15)). Each party may use any legal process to resolve non-medical malpractice claims.
C. The term "Provider" means the physician, group or clinic and their employees, partners, associates, agents, successors, and estates.
D. The term "Patient" or "you" means:
1. you and any person who makes a Claim for care given to YOU, such as your heirs, your spouse, children, parents, or legal representatives, AND
2. your unborn child or newborn child for care provided during the 12 months immediately following the date you sign this Agreement, or any person who makes a Claim for care given to that unborn or newborn child.
ARTICLE 3 DISPUTE RESOLUTION OPTIONS
A. Methods available for dispute resolution. We agree to resolve any Claim by:
1. working directly with each other to try and find a solution that resolves the Claim, OR
2. using non-binding mediation (each of us will bear one-half of the costs); OR
3. using binding arbitration as described in this Agreement
You may choose to use any or all of these above methods to resolve your Claim.
B. Legal Counsel. Each of us may choose to be represented by legal counsel during any stage of the dispute resolution process, but each of us will pay the fees and costs of our own attorney.
C. Arbitration- Final Resolution. If working with the Provider or using non-binding mediation does not resolve your Claim, we agree that your Claim, will be resolved through binding arbitration. We both agree that the decision reached in binding arbitration will be final.
ARTICEL 4 HOW TO ARBITRATE A CLAIM
A. Notice. To make a Claim under this Agreement, mail a written notice to the Provider by certified mail that briefly describes the nature of your Claim (the "Notice"). If the Notice is sent to the Provider by certified mail it will suspend (toll) the applicable statute of limitations during the dispute resolution process described in this Agreement.
B. Arbitrators. Within 30 days of receiving the Notice, the Provider will contact you. If you and the Provider cannot resolve the Claim by working together or through mediation, we will start the process of choosing arbitrators. There will be three arbitrators, unless we agree that a single arbitrator may resolve the Claim.
1. Appointed Arbitrators. You will appoint an arbitrator of your choosing and all Providers will jointly appoint an arbitrator of their choosing.
2. Jointly-Selected Arbitrator. You and the Provider(s) will then jointly appoint an arbitrator (the "Jointly-Selected Arbitrator"). If you and the Provider(s) cannot agree upon a Jointly-Selected Arbitrator, the arbitrators appointed by each of the parties will choose the Jointly-Selected Arbitrator form a list of individuals approved as arbitrators by the state or federal courts of Utah. If the arbitrators cannot agree on a Jointly-Selected Arbitrator, either or both of us may request that a Utah court select an individual from the lists described above. Each party will pay their own fees and costs in such an action. The Jointly- Selected Arbitrator will preside over the arbitration hearing and have all other powers of an arbitrator as set forth in the Utah Uniform Arbitration Act.
C. Arbitration Expenses. You will pay the fees and costs of the arbitrator you appoint and the Provider(s) will pay the fees and costs of the arbitrator the Provider(s) appoints. Each of us will also pay one-half of the fees and expenses of the Jointly-Selected Arbitrator and any other expenses of the arbitration panel.
D. Final and Binding Decision. A majority of the three arbitrators will make a final decision on the Claim. The decision shall be consistent with the Utah Uniform Arbitration Act.
E. All Claims May be Joined. Any person or entity that could be appropriately named in a court proceeding ("Joined Party") is entitled to participate in this arbitration as long as that person or entity agrees to be bound by the arbitration decision ("Joinder"). Joinder may also include Claims against persons or entities that provided care prior to the signing date of this Agreement. A "Joined Party" does not participate in the selection of the arbitrators but is considered a "Provider" for all other purposes of this Agreement.
ARTICLE 5 LIABILITY AND DAMAGES MAY BE ARBITRATED SEPARTELY
At the request of either party, the issue of liability and damages will be arbitrated separately. If the arbitration panel finds liability, the parties may agree to either continue to arbitrate damages with the initial panel or either party may cause that a second panel be selected for considering damages. However, if a second panel is selected, the Jointly Selected arbitrator will remain the same and will continue to preside over the arbitration unless the parties agree otherwise.
ARTICLE 6 VENUE / GOVERNING LAW
The arbitration hearings will be held in a place agreed to by the parties. If the parties cannot agree, the hearings will be held in Salt Lake City, Utah. Arbitration proceedings are private and shall be kept confidential. The provisions of the Utah Uniform Arbitration Act and the Federal Arbitration Act govern this Agreement. We hereby waive the pre-litigation panel review requirements. The arbitrators will apportion fault to all persons or entities that contributed to the injury claimed by the Patient, whether or not those persons or entities are parties to the arbitration.
ARTICLE 7 TERM / RESCISSION / TERMINATION
A. Term. This Agreement is binding on both of us for one year from the date you sign it unless you rescind it. If it is not rescinded, it will automatically renew every year unless either party notifies the other in writing of a decision to terminate it.
B. Rescission. You may rescind this Agreement within 10 days of signing it by sending written notice by registered or certified mail to the Provider. The effective date of the rescission notice will be the date the rescission is postmarked. If not rescinded, this Agreement will govern all medical services received by the Patient from Provider after the date of signing, except in the case of a Joined Party that provided care prior to the signing of this agreement (see Article 4(E)).
C. Termination. If the Agreement has not been rescinded, either party may still terminate it at any time, but termination will not take effect until the next anniversary of the signing of the Agreement. To terminate this Agreement, send written notice by registered or certified mail to the Provider. This Agreement applies to any Claim that arises while it is in effect, even if you file a Claim or request arbitration after the Agreement has been terminated.
ARTICLE 8 SEVERABILITY
If any part of this Agreement is held to be invalid or unenforceable, the remaining provisions will remain in full force and will not be affected by the invalidity of any other provision.
ARICLE 9 ACKNOWLEDGEMENT OF WRITTEN EXPLANATION OF ARBITRATION
I have received a written explanation of the terms of this Agreement and I have been verbally encouraged to read it and this Agreement. I have had the right to ask questions, I have been verbally encouraged to ask any questions, and I have had all my questions answered. I understand that any Claim I might have must be resolved through the dispute resolution process in this Agreement instead of having them heard by a judge or jury. I understand the role of the arbitrators and the manner in which they are selected. I understand the responsibility for arbitration related costs. I understand that this Agreement renews each year unless cancelled before the renewal date. I understand that I can decline to enter into the Agreement and still receive health care. I understand that I can rescind this Agreement within 10 days of signing it.
ARTICLE 10 RECEIPT OF COPY. I HAVE RECEIVED A COPY OF THIS DOCUMENT
Name of Physician Group or Clinic:
Salt Lake Eye Associates LLC
Name of Patient (Print)
Signature of Physician or Authorized Agent
Signature of Patient & Date (sign in office)
Should be Empty: