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Patient Name*

Gender

Last 4 SS#*

Address

Date of Birth*

Primary Phone*

Secondary Phone

Email*

Employer/Occupation*

Marital Status

Last Physical Date

Primary Care Physician Name / Location

Are you here for ...

Glasses

Contacts

Both

Medical Information and History

# alcoholic drinks per week

Tobacco / Vape Use?

Pregnant or nursing?

Any Eye Infections/Diseases? Injuries/Surgeries

Interested in refractive surgery?

Yes

Type of Contacts Worn

Type/Brand CL Solutions Used

List ALL Medication Taken

List ANY Allergies

Have you or any blood relatives had any of the following? Please indicate: Se=Self Mo=Mother Fa=Father Si=Sister Br=Brother GM=Grandmother GF=Grandfather So=Son Da=Daughter

High Cholesterol

High BP

Diabetes 1 or 2

Stroke

Lupus

Head Injury

Cancer

Migraines

Blindness

Glaucoma

Macular Degeneration

Cataracts

Lazy Eye

Turned Eye

Color Blindness

Detached Retina

Is there any other information that will help the doctor and/or staff with your exam? (conditions, disabilities, limitations, etc.)

HIPAA Notice of Privacy Practices - Acknowledgement of Receipt

The privacy of your medical information is important, and we are committed to protecting it. To provide you with quality care and to meet federal legal requirements, we have created a record of the and services you have and will receive at Columbus Optical. If you would like a copy of the full-length Privacy Policy, please request it from the front desk.

Patient Name*

I agree and I hereby acknowledge that I have been notified of ColumbusOptical's commitment to protecting my medical information and offered access to the HIPAA Private Practices.

If you do not wear contact lenses and/or not interested in contact lenses, please disregard this section.

Shape Successful Fit Contact Lens Program

The doctors at Columbus Optical would like to welcome you to her Successful Fit Contact Lens Program. With current contact lens technology, nearly all patients are candidates for successful contact lens wear. Contact lens fitting is individual to each patient, depending on factors including prescription, cornea shape, and overall health of the eyes. Our goal for every patient is clear and comfortable vision through healthy contact lens wear with the latest technology can offer.

Contact Lens Professional Fees

To ensure successful and healthy contact lens wear, our doctors do some testing and measurements that are additional to your comprehensive exam. These tests and measurements are to ensure your eyes are healthy, your lenses are properly fit, and you are seeing your best. Contact lens professional fees cover the extra testing and time taken by our doctors and their staff for your contact lens fitting. Contact lens professional fees are additional to and not included in your comprehensive examination fee and must be paid in full at the time of your exam. These professional fees are non-refundable.

What your contact lens professional fee includes:

Custom microscopic evaluation of the contact lens fit on your eyes
Any diagnostic/trial lenses needed to finalize your contact lens prescription
Any follow-up visits within 60 days of the initial evaluation necessary to finalize your contact lens prescription
Your finalized contact lens prescription that must be renewed yearly in accordance to Indiana law

Level 1: Spherical Contact Lens Care:$65.00
Level 2: Toric/Astigmatic Contact Lens Care :$105.00
Level 3: Multifocal/Monovision/RGP Contact Lens Care:$155.00
Level 4: Complex/Medically Necessary Contact Lens Care:$205.00
Contact Lens Training: New wearers only: $35.00

Your finalized contact lens prescription may be used to purchase a supply of contact lenses. The cost of your contact lens supply is separate from the contact lens professional fee. Purchasing an annual supply of contact lenses garners additional benefits.

Purchasing an annual supply of contact lenses through Columbus Optical includes:

Extends the 60 day included follow-up period to 365 days
Trial lenses to wear until your scheduled comprehensive exam if your supply runs out prior to end of 365 day follow-up period
Exchange of unopened lenses from contact lens supply if you experience a prescription change during 365 day follow-up period*

*Exchange is 1 for 1. If the doctor and the patient decide to change lens type, the patient will be responsible for any cost difference.

Some vision plans may contribute toward the contact lens professional fee and/or your contact lens supply. Please consult your vision plan to determine if you have contact lens coverage. Your doctor would be happy to answer any of your questions regarding the Successful Fit Program as they pertain to your individual contact lens prescription.

I agree

I have read the information above regarding the Successful Fit Contact Lens Program and agree to the Contact Lens Professional Fee. I also acknowledge that I will be provided with a copy of my contact lens prescription at the completion of my fitting.

Appointment Late/No Show Policy

Thank you for trusting your optometric care to Columbus Optical Services. When you schedule an appointment with one of our doctors, we set aside enough time to provide you with the highest quality care. Should you need to cancel or rescheduled an appointment please contact our office as soon as possible. This gives us time to schedule other patients who are waiting for an appointment. Please read our late/no show policy below:

Any patient who arrives more than 15 minutes past their scheduled appointment time will be required to reschedule. If a patient arrives 1 to 15 minutes past their scheduled appointment, your doctor will make every effort to make a fair decision to see the patient at their scheduled time or ask them to reschedule as courtesy to their other patients.
Effective January 1, 2022 any patient who fails to show and has not contacted our office within 24 hours of their appointment time (before or after) will be charged a non-refundable $50.00 fee. The fee is charged to the patient, not the insurance company, and is due via phone prior to rescheduling any future appointment.
If a third No Show with no 24 hour notice should occur the patient may be dismissed from Columbus Optical Services.
As a courtesy, we attempt to make reminder calls for appointments. If you do not receive a reminder call or message, the above Policy will remain in effect.

We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances please contact our office, and we may be able to waive the No Show fee. You may contact Columbus Optical at the number below. Should it be after regular business hours, you may leave a message. Columbus Optical Services Doctors Line: 812-372-7782

I agree*

I have read and understand the Appointment Late/No Show Policy and agree to its terms.

Office Financial Policy

We are NOT on a billing system, and therefore, payment is expected at the time of service. If we agree to submit our billing to your third party payment carrier, we will do so in standardized format, to the best of our ability, and within two days of the services you receive. If we have NOT received payment by nine (9) weeks after your service date, we will expect that YOU are responsible for total payment of services rendered and pursuing your own reimbursement from your carrier. I hereby authorize payments of medical benefits to Patricia Hernacki, O.D. for any services rendered to me, and that I am responsible for any amounts not covered, as well as all co-payments, co-insurance fees, and applicable deductibles. I understand that I shall pay all attorney fees, court costs, and collection fees should they occur.
Due to the expense involved with issuing refunds, we no longer automatically return overpayments amounting to less than $15, but will hold these amounts as a credit balance in your name unless directed otherwise.

NOTICE OF PRIVACY PRACTICES - FEDERAL REQUIREMENT This notice takes effect of December 2002 and remains in effect until we replace it.
OUR PLEDGE REGARDING MEDICAL INFORMATION:
The privacy of your medical information is personal and we are committed to protecting it. To provide you with quality care and to meet certain legal requirements we have created a record of the care and services you have received here.
OUR LEGAL DUTY REQUIRES US TO:
1) Keep your medical information private; 2) Give you this notice of our duties/practices and your rights regarding your medical information; 3) Follow the terms of the notice now in effect. We have the right to change our privacy practices and the terms at any time for even previously created medican information, provided the changes are permitted by law.
USE AND DISCLOSURE OF MEDICAL INFORMATION:
We will not use or disclose your medical information for any purpose not listed below without your written authorization. Any specific written authorization you provide may be revoked at any time by writing to us. We may typically disclose your medical information in order to carry out any treatment, appointment, payment, or health care operations. Less commonly, we will release in request by medical government organization (e.g. FDA, CDC, coroner, public health, etc.); to military personal and veterans; to national security and intelligence; to protective services (e.g. suspect, fugitive, material witness, crime victim, missing person, etc.); to correctional institutions and other law enforcement; to government programs providing public benefits; for court orders (e.g. subpoena, discovery request, warrant, grand jury, etc.); to workers compensation programs; to report blindess; or when necessary to prevent a serious threat to your health/safety or to the health/safety of others.
YOU ARE ENTITLED TO:
1) Look at or get copies of your medical information (photocopies at $3.50 per page, plus postage); 2) Receive a list of the times we have shared your medical information; 3) Request that we place additional restrictions on our disclosures or use of your medical information; 4) Request in writing that we change your medical information; 5) Request a paper copy of any electronic copy you have received; 6) Request confidential communications with you.
QUESTIONS OR COMPLAINTS:
Please contact Patricia Hernacki, O.D. or her office staff by mail at 2475 Cottage Ave., Columbus, IN 47201 or by phone at 812-372-7782. If you think that we may have violated your privacy rights, please contact the person named above and submit a written complaint to the U.S. Department of Health and Human Services. We can provide you with the address needed, and will not retaliate in any way if you choose to file a complaint.

NOTICE OF POSSIBLE INSURANCE/MEDICARE DENIAL
We will submit a copy of our charges to Medicare. We are a non-participating provider of services and do not typically accept assignment of benefits from Medicare except in some cases of foreign body removal, glaucoma treatment, cataract co-management, punctual occlusion, or photography. Medicare will only pay for services that it determines to be "Reasonable and Necessary" under section 1862(a)(1) of the Medicare Law. Therefore, it is possible that Medicare may deny payment for any service(s) that you receive. We will do our best to "code" your services so as to receive reimbursement, but this cannot be guaranteed. Your signature above authorizes us to release medical information to an insurer.

I Understand*

I have read the above financial agreement and understand.

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Online Check-In

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