Patient General Consent & Financial Responsibility Form

Name: Texas State Optical
Address: 101 South Interstate 35, Courtyard Plaza, New Braunfels, TX, 78130, US
Telephone: (830) 201-3237
Price range: $000 - $300

PATIENT’S LEGAL NAME*
First Middle Last
Date of Birth
MM slash DD slash YYYY
- NEW PATIENT
- RETURNING
INDIVIDUAL RESPONSIBLE FOR PAYMENT OF UNPAID BALANCES
NAME
RELATIONSHIP TO PATIENT
FAMILY MEMBER OR OTHER PERSONS WE MAY INFORM ABOUT YOUR MEDICAL CONDITION/ DIAGNOSIS
NAME RELATIONSHIP PHONE NUMBER
PATIENT’S BILLING INFORMATION
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
HOME NUMBER
MOBILE 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 NUMBER
Can 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 SIGNATURE
VISION 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 SHARED
NAME
DATE OF BIRTH
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
PHONE NUMBER
EMPLOYER
SOCIAL SECURITY NUMBER
PRIMARY CARE PHYSICIAN NAME
PRACTICE NAME
Please Initial the Three Statements Below
SINCE 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

NAME	RELATIONSHIP	PHONE NUMBER

Please Initial the Three Statements Below

Texas State Optical

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