Your Eye Doctor

Dr. Andrew Chan
Dr. Zoe Stein

Date

ALBERTA HEALTH #

Name

First Last

Birth Date

M
F

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home #

Preferred

Cell #

Preferred

Work#

Preferred

Email

Preferred

OCCUPATION:

CONTACT PERSON:

CONTACT PHONE #:

Who referred you to this office?

Please specify

Date of last EYE EXAM:

by Dr.

Date of last MEDICAL EXAM:

by Dr.

Do you wear glasses?

Yes
No

Contact lenses?

Yes
No

If yes, what lens brand?

Medical condition(s)?

Allergies?

Current medications?

Eye drops used:

Do you have these symptoms (even with your current lens Rx)? Please check off all that apply:

Eye & Medical Health History – Please check off all that apply for yourself or a family member.

	You	Family
Glaucoma
Macular Degeneration
Retinal Detachment
Cataracts
Colour Deficiency
Lazy Eye
Eye Turn (in / out)
Diabetes
Hypertension
Thyroid Disease
Arthritis
Heart Disease
Kidney/Liver Problem
Eye Surgery
Other

If other please specify

Privacy protection form reviewed and accepted. Signature:

We respect your right to privacy and will not disclose any of this information without your consent.

NOTE TO PATIENT:
We want your informed consent. This means that we want you to understand the services we will provide to you and what we do with the personal information that we obtain about you. If you have any questions about this, please ask.

CONSENT FOR PERSONAL INFORMATION:
I understand that to provide me with optometric/optical services and products, this practice will collect some personal information about me, e.g. home telephone number, address, health number e-mail address, medications used, etc.

I understand that my medical information or lens prescriptions will not be released to others without my written consent. As explained in this document, there are some rare exceptions to these commitments as required by law. I agree to this practice collecting, using and disclosing personal information about me as set out and in this Privacy Policy.
I understand that I may receive without request, some of the following notices and information. If I do not want to receive some of this information, I agree to advise the practice of my refusal in writing. If e-mail address is updated, consent will be applied to new e-mail address for the following mentioned patients.

	Yes	No
Appointment reminders by e-mail, mail or telephone
Other informational mailings from this practice by e-mail or mail
Notice of promotions and special offers by e-mail
Information relevant to my medical condition by e-mail, mail or telephone
Inform of product delivery by e-mail or telephone

I have reviewed Foresight Eyecare's Privacy Policy with respect to the collection, use and disclosure of personal information, steps taken to protect the information and my right to review my personal information. I understand how this Privacy Policy applies to me. I have been given a chance to ask my questions I have about this Privacy Policy and they have been answered to my satisfaction.

E-mail address:

E-mail account holders

Signature

Family members under the same e-mail:

Date

Electronic transmission authorization and consent

Primary coverage insurer/payer

Primary coverage plan member name

Primary coverage policy number (also referred to as group or contract number)

Primary coverage certificate (also referred to as member/identification number)

(Canada Life only) secondary coverage plan member name

Consent to collect and exchange personal information

Purpose

Personal information that we collect and disclose about you, and if applicable, is used by the insurer, and/or plan administrator of your group benefits plan, its affiliates and their service provider(s) for the purposes of assessing eligibility for your claims, underwriting, investigating, auditing and otherwise administering the group benefit

Authorization and consent

I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes.

I authorize such insurer and / or plan administrator and their service provider(s) to:
• use my personal information for the above purposes.
• exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits, or other benefits programs, other organizations, or service providers working with such insurer and/or plan administrator or any of the foregoing, when relevant for the above purposes.
• where applicable exchange personal information concerning any claims with any assignee of benefits payable and exchange personal information for the above purposes electronically or in any other manner.

I understand that personal information may be subject to disclosure to those authorized under applicable law.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the
continued administration of the group benefits plan.

In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning any claims submitted, I acknowledge and agree
that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant
organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and
where applicable my employer or benefit plan sponsor, for the purposes of investigation and prevention of fraud and/or benefit plan
abuse. I understand that the submission of fraudulent claims is a criminal offence.

If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group
benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where
applicable, my benefit plan sponsor, for that purpose.

If the patient is a person other than myself, I confirm that the patient has given their consent to provide their personal information for the
healthcare provider and the insurer and/or plan administrator and their service provider(s) to use and disclose their personal information
as set out above.

I accept the terms and conditions

Benefit assignment form

I hereby assign benefits payable for the eligible claims to the healthcare provider responsible for submitting my claims electronically to
the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to such provider. In the event my claim(s)
are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the healthcare provider for any services rendered and/ or supplies provided.

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this benefit assignment form, that any
benefit payment made in accordance with this benefit assignment form will discharge the insurer/plan administrator of its obligations
with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be
discharged of its obligation with respect to that benefit payment.

I understand that this assignment will apply to all eligible claims submitted electronically by my healthcare provider and that I may revoke
it at any time by providing written notice to the insurer/plan administrator.

If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the
healthcare provider

I accept the terms and conditions

Signature of plan member

All information contained herein is protected by privacy laws including the Personal Information Protection and Electronic Documents Act (PIPEDA) and all the corresponding provincial legislation. All users agree to protect the personal health information contained herein from unauthorized use, disclosure, loss, theft, or compromise in accordance with the above noted laws and with at least the same care employed to protect their own confidential information. Any unauthorized access, disclosure or use of this information is illegal.

ADULT PATIENT INFORMATION FORM