Patient History Questionnaire
Financial Agreement
Privacy Policy
COVID Screening Questions
Consent for Electronic Delivery of Prescriptions

Patient History Form

DR. KURTBAY OPTOMETRY

  750 IRVING STREET

  SAN FRANCISCO, CA 94122

  415-759-5448

VISION INSURANCE INFORMATION

MEDICAL HISTORY

Do you have known problems with any of these systems? (Please select all that apply) 

Please answer all that apply: 

FAMILY HISTORY


PERSONAL EYE INFORMATION

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FINANCIAL AND INSURANCE POLICY:

We are committed to providing you with the best possible service and are pleased to

discuss and explain our professional fees with you at any time. Your clear understanding of our financial and insurance policy is important to our professional relationship

  •  24hr notice is required when re-scheduling or canceling an appointment or you will be billed $75 for failure of notification.
  •  Patients who are 15 minutes late or more may need to reschedule or wait
  • Full payment is due at the time of service unless other arrangements are made prior to seeing the doctor.
  • For your convenience, our office accepts cash, ATM, and all major credit cards.
  • We do not accept checks.

FOR PATIENT’S WITH VISION INSURANCE:


In our ongoing effort to assist our patients, please present your insurance information

prior to services being rendered. We are unable to honor your insurance should you

provide the information after the initiation of services.


If you are unsure of the status of your insurance, please verify that it is active and available prior scheduling an appointment.


Our office will be happy to submit your insurance claims. Please understand that your insurance company, not our office, determines your vision benefits.


 I acknowledge that it is my responsibility to know and understand my vision insurance benefits. I agree to be responsible for all fees not covered by my vision insurance or should my insurance company deny payment to Dr. Kurtbay Optometry. 


  INFORMED CONSENT AND DISCLOSURE:


I have read, understood, and agree to the above and I authorize “Dr. Kurtbay Optometry” to submit and to sign insurance claims on my behalf. I also authorize the release of any information pertinent to my insurance company or their agents. I understand that this authorization is a direct assignment of my rights and benefits under my policy and that the payments will be paid directly to “Dr. Kurtbay Optometry.”

ALL DELINQUENT ACCOUNTS, IF NOT RESOLVED BY OUR OFFICE IN A TIMELY MATTER, WILL BE FORWARDED TO A COLLECTIONS AGENCY. 

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PRIVACY POLICY:


CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS  


In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our

services, and to conduct health care operations involving our office.


We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this consent document. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health care professional. Similarly, the use and disclosure of your health information for purposes of payment includes submission of your health information to third-party payers or insurers for claims review, determination of benefits and payment; our submission of your health information to auditors hired by third-party payers and insurers, among other aspects of payment described in our Notice of Privacy Practices. We do not provide such information to third-party payers and insurers if the patient does not have vision insurance.


Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at our office.


When you sign this consent document, you signify that you authorize us to use and disclose your health information to treat you, to obtain payment for our services, and to perform health care operations. You can revoke this consent in writing at any time, unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. We can decline to serve you if you elect not to sign this consent form.


You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or health care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do agree, the restrictions are binding to us. Our Notice of Privacy Practices

describes how to as for a restriction.


I HAVE READ THIS CONSENT AND UNDERSTAND IT. I CONSENT TO THE USE AND DISCLOSURE OF MY HEALTH INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH

CARE OPERATIONS.

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Covid Screening and Protocol Acknowledgement

  1. All places of contact (equipment, tools, pens, chairs, tables) are disinfected between each patient visit.
  2. All interactions will be as touchless as possible.
  3. All frames, including frames brought for adjustment, are washed with a disinfectant solution and soap.
  4. Restrooms are currently unavailable due to higher transmission risk.
  5. Masks are only required during the exams/follow ups. **Masks are no longer required in the front office for cases such as pick ups or frame selections. ** 

By signing this document, I understand Dr. Kurtbay Optometry is taking measures to mitigate the risks of infection and will not hold my doctor or office staff responsible if I contract Covid-19 or any other virus.


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Consent For Electronic Delivery of Prescription

I acknowledge that my prescription for glasses and/or contact lenses will be sent to me via email.