3416 Bechelli Ln Redding, CA 96002 • (530) 222-7290 • Office@DrGussenhoven.com

3416 Bechelli Ln Redding, CA 96002

(530) 222-7290 • office@drgussenhoven.com

3416 Bechelli Ln Redding, CA 96002

(530) 222-7290

office@drgussenhoven.com

New Patient Forms for Minors

These forms are required for all patients under 18 years old.

    OCULAR AND MEDICAL HISTORY QUESTIONNAIRE FOR MINOR


    MF

    YN

    Parent or guardian, please complete all personal and employment information.
    MEDICAL HISTORY

    YN

    YN
    FAMILY MEDICAL AND OCULAR HISTORY
    DISEASE / CONDITION

    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?


    YESNO?



    YESNO?

    SOCIAL HISTORY
    (This information is kept confidential. You may discuss this portion directly with the doctor if you prefer.)

    Yes

    YESNO

    YESNO

    YESNO

    YESNO


    YESNO


    YESNO

    REVIEW OF SYSTEMS
    OCULAR (Eyes)

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?
    NEUROLOGICAL

    YESNO?

    YESNO?

    YESNO?

    YESNO?
    ALLERGIC/IMMUNOLOGIC

    YESNO?

    YESNO?
    MUSCULOSKELETAL

    YESNO?

    YESNO?

    YESNO?
    CONSTITUTIONAL

    YESNO?

    YESNO?

    YESNO?
    EARS, NOSE, MOUTH, THROAT

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?
    ENDOCRINE

    YESNO?

    YESNO?
    GASTROINTESTINAL/GENITOURINARY

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?

    YESNO?
    INTEGUMENTARY

    YESNO?

    YESNO?
    LYMPHATIC / HEMATOLOGIC

    YESNO?

    YESNO?
    PSYCHIATRIC

    YESNO?

    YESNO?

    YESNO?
    RESPIRATORY

    YESNO?

    YESNO?

    YESNO?
    VASCULAR / CARDIOVASCULAR

    YESNO?

    YESNO?

    YESNO?

    DEVELOPMENTAL HISTORY FOR MINOR

    PRESENT SITUATION


    Yearly examinationBlur at distanceBlur at nearEyes hurtReferralOther

    YesNo

    VISUAL HISTORY




    Family vision conditions





    YesNo



    YesNo


    YesNo


    YesNo


    Soft DisposableSoft Extended WearGas Permeable

    YesNo

    All of the timeDistance OnlyNear Only

    GENERAL BEHAVIOR


    YesNo

    YesNo


    SCHOOL




    YesNo

    YesNo

    YesNo

    Child’s academic performance:


    Above averageAverageBelow Average

    Above averageAverageBelow Average

    Above averageAverageBelow Average

    Above averageAverageBelow Average

    YesNo


    YesNo

    YesNo





    One eye turned in or outFrequent blinkingRubbing of the eyesFrequent reddening or tearing of the eyesEncrusted eyelids or frequent styesHeadachesEyes burning or watering after readingBlur at far or near after or during readingLoses place often during readingNeeds finger or bookmark to keep placeHead turns when reading across pageToo frequently omits wordsRereads or skips lines unknowinglyDisplays short attention span for reading or copyingComplains of seeing double, words run togetherRepeats letters within wordsMisaligns digits in number columnsSquints, closes, or covers one eyeTilts head extremely while workingConsistently shows gross postural deviations while working at deskVery slow reading speedFatigues quickly while doing near workComprehension reduces as reading continuesHolds book very close; head too close to deskAvoids all possible near-centered tasksLaborious readingHas good vocabulary but reading comprehension and retention are very lowMakes frequent errors in copyingSquints to see the chalkboard or moves closerMistakes words with similar beginningsReverses words, letters, or numbersConfuses likenesses and minor differencesFails to visualize what is readWhispers to self for reinforcement while readingReturns to 'drawing with fingers' to decide likes and differences and for counting

    PRENATAL, PERINATAL, POSTNATAL AND DEVELOPMENTAL HISTORY


    YesNo

    YesNo


    YesNo

    YesNo

    YesNo

    YesNo

    FAMILY AND HEALTH HISTORY



    YesNo


    REPORT


    YesNo





    If submitting as a personal representative of the patient, describe the relationship to the patient and the source of authority to sign this form:

    By submitting this form, I certify all information is true and correct to the best of my knowledge.

    Receipt of Notice of Privacy Policies & Consent Form

    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.

    The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service 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 professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office.

    When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services, and to perform healthcare operations. You also signify that you have received a copy of our Notice of Privacy Practices.

    You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

    I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Julie Gussenhoven, O.D.

    Notice of Privacy Practices

    Effective date of notice: April 14, 2003

    This notice describes how medical information about you may be used and disclosed, and how you can obtain access to this information. Please review it carefully.

    General Rule

    We respect our legal obligation to keep health information that identifies you, private. The law obligates us to give you notice of our privacy practices.

    Generally, we can only use your health information in our office or disclose it outside of our office, without your written permission, for purpose of treatment, payment or healthcare operations. In most other situations, we will not use or disclose your health information unless you sign a written authorization form. In some limited situations, the law allows or requires us to disclose your health information without written authorization.

    Uses or Disclosures of Health Information

    Examples of how we use information for treatment purpose:

    • When we set up an appointment for you.
    • When our technician or doctor tests your eyes.
    • When the doctor prescribes glasses or contact lenses.
    • When the doctor prescribes medication.
    • When our staff helps you select and order glasses or contact lenses.
    • When we show you low vision aids.

    We may disclose your health information outside of our office for treatment purposes, for example:

    • If we refer you to another doctor or clinic for eye care or low vision aids or services.
    • If we send a prescription for glasses or contacts to another professional to be filled.
    • When we provide a prescription for medication to a pharmacist.
    • When we phone to let you know that your glasses or contact lenses are ready to be picked up.

    Sometimes we may ask for copies of your health information from another professional that you may have seen before.

    We may use your health information within our office or disclose your health information outside of our office for payment purposes. Some examples are:

    • When our staff asks you about health or vision care plans that you may belong to, or about other sources of payment for our services.
    • When we prepare bills to send to you or your health or vision care plan.
    • When we process payment by credit card and when we try to collect unpaid amounts due.
    • When bills or claims for payment are mailed, faxed, or sent by computer to you or your health or vision plan.
    • When we occasionally have to ask a collection agency or attorney to help us with unpaid amounts due.
    • You can ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using e-mail to your personal email address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to Julie Gussenhoven, OD at the address, fax, or email shown at the beginning of this notice.
    • You can ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. Primarily, however, you will be able to review or have a copy of your health information within 30 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally required. By law, we can have one 30-day extension of the time for use to give you access or photocopies if we sent you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice.
    • You can ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to person who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice.
    • You can get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want), except disclosures for purposes of treatment, payment or health care operations, disclosures made in accordance with an authorization signed by you, and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30-day extension of time if we notify you of the extension in writing. If you want a list, send a written request to Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice.

    Our Notice of Privacy Practices

    By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time in compliance with and as allowed by law. If we change this notice, the new privacy practices will apply to your health information that we already have, as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, and have copies available in our office.

    Complaints

    If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to Julie Gussenhoven, OD at the address, fax, or e-mail shown at the beginning of this notice. If you prefer, you can discuss your complaint in person or by phone.

    For More Information

    If you want more information about our privacy practices, call or visit Julie Gussenhoven, OD at the address or phone number shown at the beginning of this notice.

    Optometry in Redding

    Julie Gussenhoven, OD offers Family Optometry services in Redding CA and its surrounding areas. For professional vision and eye care call (530) 222-7290 today.