15 & Under Welcome Forms for Soonercare Patients WELCOME Thank you for choosing our office for your eyecare needs. We're glad to help if you have questions All Patient Information is Confidential Name First Last Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Cell PhoneHome PhoneText OK? Email Birthdate MM slash DD slash YYYY Patient's SSNEmployer Primary Physician/Pediatrician Marital Status Children Height Weight Preferred Method of Communication Text Email Cell Phone Home Phone Preferred Language English Spanish Race: (optional) American Indian or Alaskan Native Black or African American Native Hawaiian or Pacific Islander Asian Hispanic White Preferred Pharmacy PhoneInsurance Information If you are using insurance, we need to copy your medical and vision cards. We treat both medical eye problems as well as vision care. Thank you.Primary Member's Name Primary Member's Name: Employer Primary's social securityPrimary Member's Birthdate MM slash DD slash YYYY Your Eye Health and Vision are important to usHealth HistoryPlease indicate if you or your family (blood relatives only) have any of the following Condition:Diabetes Patient Family High Blood Pressure Patient Family High Cholesterol Patient Family Heart Disease Patient Family Kidney Disease Patient Family Thyroid Disease Patient Family Asthma Patient Family Cancer Patient Family Glaucoma Patient Family Cataracts Patient Family Turned Eye Patient Family Lazy Eye Patient Family Eye Injury Patient Family Eye Surgery Patient Family Blindness Patient Family Macular Degeneration Patient Family Other Systemic Conditions Please indicate if any of the following conditions apply to you Pregnant Drug allergies Frequent Headaches Allergies Sinus trouble Smoker Please list all medications your are allergic to None Please list all medications your are allergic to Medications you are currently taking None Medications you are currently taking Approximate Date of Last Eye Exam? 1 year 2 years 3 or more years Do you currently wear glasses? Yes No If yes, when do you wear your glasses? All the time Reading/Near work Distance tasks only work Work Safety Computer wear Are you planning on getting new glasses today? Yes No Unsure Have you ever worn contact lenses? Yes No Are you renewing your contact lens prescription today? Yes No Unsure Do you work on a computer more than 4 hours per day? Yes No Are you interested in Laser Vision Correction? Yes No How did you become aware of our practice? friend recommendation co-worker recommendation referred by other professional insurance provider Payment Information I authorize you to bill my insurance for any applicable services or products, and I understand that payments for non-insured services are due the same day services are rendered SignatureNotice of Privacy Practice Methods of Payments No Insurance? No problem. Harrel Eyecare offers a discount for all non-insurance patients for their Vision or Medical exam. We also, accept all major credit cards, Care Credit, cash or checks Vision Plans Some vision insurance plans do not provide an insurance card. Vision plans usually include benefits towards glasses or contacts. (Examples: VSP, EyeMed, Avesis, Superior Vision, etc.). Medical insurances generally do not cover these benefits. Medicaid (Soonercare) only allows glasses for patients less than 20 years of age and they do not cover contact lenses. Medical Insurance Refractions (checking vision) & the contact lens portion of the exam are not generally covered by medical plans. We can file your insurance on your behalf, but this does not guarantee payment and any balance will be paid by you. If your deductible has not been met for the year, you will be responsible for services rendered. We keep medical insurance information on file because we perform medical eye care. We use medical insurance for infections, foreign body removals, eye disease, treatments, etc. We are glad to answer any questions regarding your insurance benefits. Thanks! Please Sign Here - Privacy Practices I acknowledge that I have read or have had the opportunity to read the Notice of Privacy Practices (available at the front desk). Patient Name Date MM slash DD slash YYYY Signature of Patient or GuardianMonte Harrel O.D., F.C.O.V.D. Tiffany Harrel, O.D. Savanah Sayler, O.D. 4520 S. Harvard Ste. 135 Tulsa, OK 74135 pho: 918-745-9662 fax: 918-392-7006 www.oklahomavision.com Please check any that apply to help us know how to provide the best care for your child. Developmental Checklist Slow reader Tracking issues: points with finger, omits small words while reading or copying Obsessed with routines or difficultly with transitions? Poor reading comprehension Homework takes longer than it should Hand flapping or toe walking Short attention span, restless, unable to stay on task Avoids close work Difficultly toilet training or issues with bed wetting Irregular sleep patterns Unreasonable fears, high anxiety, or night terrors Rubs eyes, squints or blinks excessively Double vision Are there any digestive/elimination problems Smart in everything but school Check if your child does not eat any of these foods Milk Meats Vegetables Fruits Has individual educational plan (IEP) Resource room for Tutor for Resource room for Tutor for Has repeated grade grade Dietary modification in place Does your child take medicine for a health problem? (do not include vitamins, iron, or fluoride) Confuses left and right repeatedly Headaches after close work Frustration, fatigue, stress after/during close work Unusual posture/head tilt while reading or writing Tactile defensiveness (clothing tags, food textures) History of seizures History of ear infections Difficultly showing affection or shows lack of empathy Frequent meltdowns/tantrums Angry or aggressive behavior issues Does your child have food allergies? Does your child use a feeding tube or other special feeding methods? Speech therapy - on track now? Difficultly with fine motor skills (eating writing holding crayon) large motor skills (riding bike, balancing, throwing/catching ball) Does your child have a problem with a. Sucking b. Swallowing c. Chewing d. Gagging Does your child refuse to eat, throw food, or do other things that upset family dinner? “SoonerCare will provide for payment of lenses and frames for children only. This Coverage includes one set of lenses and frames per service year.” -Garth L Splinter, M.D., M.B.A State Medicaid Director We offer a one year warranty on all of our frames; one replacement frame may be obtained within one year of the exam date. Pieces of broken frame are required for any replacement; loss and theft are not covered by this warranty. Lenses are covered under a one year Scratch Warranty. Damaged lenses are required for replacement, and may only be obtained once within the year of exam date. This warranty is courtesy of Harrel Eye Care Center and is not affiliated in any way to your SoonerCare Coverage. If frame or lenses have been replaced under warranty or a replacement is needed due to loss or theft, the prices are as follows: $74.00 frame only $68.00 lenses only $99.00 frame and lens package price “The replacement of or additional lenses and frames are allowed [to be billed to SoonerCare] only when medically necessary [as prescribed by doctor]… The replacement of lenses and frames due to abuse and neglect by the member is not covered.” -OAC 317:30-5-432.1 If you have any questions, please call your SoonerCare Case Worker. If you would like to see a copy of the clarification letter in accordance with OAC 317:305-432.1 please ask an associate. I acknowledge that I have read and understand the above Advisement and consent to the contents. Patient Name Date MM slash DD slash YYYY Signature Patient or Guardian Print this form
