Dr. Michael T. Craig, M.D.

Advanced Vision Care, Inc.

NEW PATIENT LETTER

(complete form in ink only)

Dear New Patient:

Thank you for selecting Dr. Craig and Advanced Vision Care, Inc. for your next eye
examination.
We look forward to your examination time with us.
The following pages include forms that we require to process you into our office.
Please fill out each of them as completely as possible and bring them with you to
your appointment.
PLEASE BRING DRIVERS LICENSE AND INSURANCE CARDS
TO ALL APPOINTMENTS.
Although you are ultimately responsible for your insurance, we will do all we can to
file your insurance claim on your behalf. However, you are responsible for knowing
what you need as far as pre-authorization, what plans you are eligible for, etc. Please
call your insurance company to check on your coverage.
Feel free to call us with questions.
Again, welcome to our office!

1005 Bellefontaine Avenue, Suite #140, Lima OH 45804

419-991-3937 (Ph)

419-991-3939 (Fax)

Dr. Michael T. Craig, M.D.

Advanced Vision Care, Inc.

HIPAA PRIVACY RULE

BACKGROUND - The HIPAA Privacy Rule* gives you a fundamental right to be informed of the
privacy practices of Advanced Vision Care, Inc., as well as to be informed of your privacy rights with
respect to your personal health information. In compliance with this rule, Advanced Vision Care, Inc.
provides a clear explanation of these rights and practices. This Notice of Privacy Practices for Protected
Health Information is intended to focus on privacy issues and concerns, and to prompt you to have
discussions with Advanced Vision Care, Inc. and exercise your rights. If you wish to view this document
in its entirety, please click here.

ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
I HAVE RECEIVED AND READ OR HAVE BEEN GIVEN THE OPPORTUNITY
TO RECEIVE AND READ A COPY OF THE ADVANCED VISION CARE INC.
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
AND UNDERSTAND THAT MY PROTECTED HEALTH INFORMATION MAY BE
USED BY ADVANCED VISION CARE, INC. AS DESCRIBED IN THE NOTICE. I
UNDERSTAND THAT IF I HAVE ANY QUESTIONS REGARDING THE NOTICE
OR MY PRIVACY RIGHTS, I MAY CONTACT THE OFFICE ADMINISTRATOR
IN PERSON OR AT 419-991-3937 DURING REGULAR OFFICE HOURS.
PATIENTS SIGNATURE: ____________________________________
DATE: ____________________
*To

review the entire Rule and for other additional helpful information about how it applies, see the
website: http://www.hhs.gov/ocr/hipaa .

1005 Bellefontaine Avenue, Suite #140, Lima OH 45804

419-991-3937 (Ph)

419-991-3939 (Fax)

Dr. Michael T. Craig, M.D.

Advanced Vision Care, Inc.

PERSONAL INFORMATION
(complete form in ink only)

Please Print:

Male _____ Female _____

Name: First: _________________________ MI: ____ Last: ______________________________

Social Security Number: ___________________________________________________________
Address: ________________________________________________________________________
City: _____________________________________ State: _________ Zip: ___________________
Date of Birth: ________________________
Home Phone: ___________________________ Cell Phone: ______________________________
Employer: ______________________________________________________________________
Employer Address: ___________________________________ Phone: _____________________
Marital Status: (circle one) Single Married Divorced Widowed
Spouse: Name: _____________________________________ Date of Birth: _________________
Spouse: Social Security Number: ____________________________________________________
Parent or Guardians Name: _________________________________________________________
Spouse or Guardians Employer: _____________________________________________________
Emergency Contact: __________________________________ Phone: ______________________
Family Doctor: _____________________________ Optometrist: ___________________________
Referring Doctor: _________________________________________________________________

IF YOU ARE UNABLE TO COME IN FOR A SCHEDULED APPOINTMENT, PLEASE CALL

TO CANCEL AT LEAST 24 HOURS AHEAD TO AVOID A $25 FEE BEING CHARGED TO
YOUR ACCOUNT.
THERE WILL BE A $10 PER FORM CHARGE TO COMPLETE ANY DISABILITY PAPERS.
WE WILL NEED TO MAKE A COPY OF YOUR INSURANCE CARDS AND DRIVERS
LICENSE. PLEASE SHOW THEM TO THE RECEPTIONIST.
PLEASE SIGN THE INSURANCE RELEASE FORM AS WE CANNOT FILE YOUR
INSURANCE WITHOUT YOUR SIGNATURE.
*** IF YOU DO NOT HAVE INSURANCE, WE ASK THAT PAYMENT BE MADE AT THE
TIME OF SERVICE.
1005 Bellefontaine Avenue, Suite #140, Lima OH 45804

419-991-3937 (Ph)

419-991-3939 (Fax)

Dr. Michael T. Craig, M.D.

Advanced Vision Care, Inc.

PERSONAL HEALTH HISTORY

(complete form in ink only)

Name: _________________________ Sex: M / F Date of Birth: __________ Date: _________

MEDICAL HISTORY:
Do you have / had any of the following medical problems (even if currently controlled)?
___Anxiety/Depression
___Heart Disease (specify) ____________________
___Arthritis
___Hepatitis
___Asthma/Bronchitis/Emphysema
___High Blood Pressure
___Bleeding Tendencies
___Stroke
___Cancer (specify) _______________
___Ulcers
___Diabetes
___Venereal Disease
___Headache
___Other (specify) ___________________________
SOCIAL HISTORY:
Do you use tobacco?
Do you drink alcohol?

Yes / No
Yes / No

FAMILY HISTORY:
Do or did your parents/siblings/children have:
___Blindness
___Diabetes
___Glaucoma
___Macular Degeneration

If yes, how much? _______________

If yes, how much? _______________
PAST SURGERIES:
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________

PLEASE CIRCLE THE ANSWER THAT BEST FITS YOUR SITUATION:

1. Does your Vision (with Glasses, if used) make it a problem for you to:
Never
Sometimes
Frequently
a. Read traffic signs
0
1
2
b. Drive during daytime
0
1
2
c. Drive at night
0
1
2
d. See steps
0
1
2
e. Read (medicines / newspapers / etc.)
0
1
2
f. Watch television
0
1
2
g. Identify colors
0
1
2
h. Do things you have done in past
0
1
2
2. Are you hindered, limited, or disabled by glaze (dazzling lights) when:
a. Doing normal daily activities
b. Facing sun / oncoming headlights

0
0

1
1

2
2

3. Did you need assistance filling out this form because of your vision? Y / N
1005 Bellefontaine Avenue, Suite #140, Lima OH 45804

419-991-3937 (Ph)

419-991-3939 (Fax)

Dr. Michael T. Craig, M.D.

Advanced Vision Care, Inc.

MEDICATIONS
(complete form in ink only)

NAME: _____________________________________________

DATE: ___________________

Please list ALL prescription and non-prescription medications that you are taking:
Medication

Strength

How Often

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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______________________________________________________________________________
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______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

1005 Bellefontaine Avenue, Suite #140, Lima OH 45804

419-991-3937 (Ph)

419-991-3939 (Fax)

Dr. Michael T. Craig, M.D.

Advanced Vision Care, Inc.

INSURANCE PAYMENT RELEASE AUTHORIZATION

(complete form in ink only)

Name of Patient

____________________________________________

Social Security Number

____________________________________________

I request that payment of authorized Medicare or Primary Insurance benefits and, if applicable,
Medigap or Secondary Insurance be made on my behalf to Advanced Vision Care, Inc. for any
services furnished me by Advanced Vision Care, Inc. I authorize any holder of medical information
about me to release to the Health Care Financing Administration and its agents any information
needed to determine these benefits or the benefits payable for related services.
__________________________________
Signature of Patient

1005 Bellefontaine Avenue, Suite #140, Lima OH 45804

__________________________________
Date

419-991-3937 (Ph)

419-991-3939 (Fax)