Patient General Consent & Financial Responsibility Form PATIENT’S LEGAL NAME* First Middle Last Date of Birth MM slash DD slash YYYY NEW PATIENT RETURNING INDIVIDUAL RESPONSIBLE FOR PAYMENT OF UNPAID BALANCESNAME RELATIONSHIP TO PATIENT FAMILY MEMBER OR OTHER PERSONS WE MAY INFORM ABOUT YOUR MEDICAL CONDITION/ DIAGNOSISNAMERELATIONSHIPPHONE NUMBER PATIENT’S BILLING INFORMATION 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country HOME NUMBERMOBILE NUMBER*MAY WE SEND YOU TEXT MESSAGES FOR APPT UPDATES? (NO SPAM) Yes No EMAIL* MAY WE SEND YOU EMAILS WITH PRACTICE ANNOUNCEMENTS? Yes No EMPLOYER SOCIAL SECURITY NUMBERCan we leave confidential messages such as appointment reminders on the home, mobile, or email provided? Yes No SPECIFIC INSTRUCTIONS ACKNOWLEDGEMENT OF PRIVACY PRACTICES NOTICE RECEIPT* I HAVE RECEIVED A COPY OF TSO NEW BRAUNFELS’ NOTICE OF PRIVACY PRACTICES WITH AN EFFECTIVE DATE OF MAY 13, 2020.PATIENT / PATIENT REPRESENTATIVE PATIENT / PATIENT REPRESENTATIVE SIGNATUREVISION PLAN NAME MEMBER/SUBSCRIBER ID NUMBER MEDICAL PLAN NAME MEMBER/SUBSCRIBER ID NUMBER PRIMARY INSURANCE HOLDER’S INFORMATION *ALL PATIENT INFORMATION IS STRICTLY CONFIDENTIAL. YOUR INFORMATION IS NEVER SHAREDNAME DATE OF BIRTH MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PHONE NUMBEREMPLOYER SOCIAL SECURITY NUMBERPRIMARY CARE PHYSICIAN NAME PRACTICE NAME Please Initial the Three Statements BelowSINCE OUR LAB BEGINS PROCESSING EACH ORDER FOR GLASSES IMMEDIATELY, WE ARE UNABLE TO MAKE ANY CANCELLATIONS AFTER THE ORDER HAS BEEN PLACED. LENSES ARE CUSTOM-MADE AND ARE NON-REFUNDABLE.* IF YOU HAVE ANY QUESTIONS ABOUT YOUR INSURANCE BENEFITS (CO-PAYS, WHAT IS/IS NOT COVERED, ETC), PLEASE ASK PRIOR TO SEEING THE DOCTOR AND WE WILL ASSIST YOU THE BEST WE CAN. ANY APPLICABLE CO-PAYS AND PAYMENT FOR ITEMS NOT COVERED BY YOUR INSURANCE MUST BE COLLECTED AT THE END OF YOUR VISIT.* I UNDERSTAND THAT FOR A CONTACT LENS EVALUATION (ACCOMPANIES EVERY CONTACT LENS EXAM BY TEXAS LAW) THE EVALUATION FEE VARIES UPON DIAGNOSIS OF PRESCRIPTION.* IN THE EVENT THAT THE SPONSOR OF YOUR INSURANCE PLAN DETERMINES THAT YOU ARE NOT ELIGIBLE AT THE TIME OF SERVICE OR MAKES A DETERMINATION THAT YOU ARE ELIGIBLE FOR A REDUCED LEVEL OF COVERAGE, BY SIGNING THIS AGREEMENT YOU AGREE TO BE FINANCIALLY RESPONSIBLE FOR ANY AND ALL OF THE CHARGES INCURRED BY YOURSELF AND THE PLAN SPONSOR.PATIENT / PATIENT REPRESENTATIVE NAME PATIENT / PATIENT REPRESENTATIVE SIGNATURE