Neuro-Visual Rehab Consult Form

I authorize to release health information identifying me. Be aware that records released may include information regarding sexuallytransmitted diseases and mental health information. The records are released under the following terms/conditions:

1) Information to be released:

2) Who information is being released to:

3) Purpose of release: Continued care / Legal / Patient Record / Referral

4) This release expires 180 days after signed below

It is your decision to sign this form. If you sign this form, you can refused to revoke it at a later day, but we have already set it to automatically expire. To revoke prior to 180 days, please tell us that in a written note with your signature, and send to the address listed on the side of this form.

When your health information is disclosed, the recipient often has no legal duty to protect it’s confidentiality and may re-disclose it as they wish. Our office protects your information, we do NOT re-disclose it without your written consent.

I would like my information sent to the recipient via:FaxMail

*Our office does not send or accept records via email, as this is an unsecured method. There is a $5.00 charge for mailing records. There is no charge for faxing records.*

I have read and understand this form. I am signing voluntarily. I authorize the disclosure of my health information as described above.

If the patient is under 18 or has a legal guardian, the legal guardian needs to sign. Describe your relationship to the patient and source of authority to sign the form.

Source of authority (guardian/parent/etc.):

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY
PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

(You may refuse to sign this form. In refusing, we will not be allowed to process your insurance claims.)

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy
Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. My signature will also serve as a PHI document release should I request treatment or imaging be sent to other attending doctors/ facilities in the future.
This HIPPA Form will serve as authorization until a new form is signed and replaces this form.

*You are normally address by first name only in the reception area. Please let us know if this is not how you would like to be addressed.**

Please list any individuals who can have access to your health information below:

Insurance Authorization Release
With the signature below, I authorize the release of any medical or other PHI necessary to process this claim and any future claims. I authorize payment of medical, eyeglass, or contact lens benefits to Russell EyeCare & Associates. (This replaces signatures for boxes 12 & 13 on CMS-1500 paper insurance forms, as RE&A files electronically.)

*I UNDERSTAND THAT I AM RESPONSIBLE TO KNOW MY INSURANCE BENEFITS AND
NETWORKS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY INSURANCE.*

Signature of Patient/ Guardian:

*We do not take the following eye care plans: VSP, EyeMed, Aetna Vision, United Healthcare Vision, BlueView, BlueVision, Optum, Spectera, Davis, or Superior Vision.*

CC: What can we do for you today?

HEALTH HISTORY

Primary Physician & Clinic

Last visit​​​​​​​

Do YOU have any EYE or MEDICAL conditions? Diabetes, High Blood Pressure, Cholesterol, etc.

Goals for Neuro-Visual Rehab (What would you like to accomplish?)

What changes would you like to see in yourself?