Patient Information Form

Patient Information

Spouse Information

Parent/Guardian Information (For Minors Only)

Emergency Contact (relative or friend that is someone NOT living with you)

Insurance Information

HIPAA

In accordance with the Health Insurance Portability and Accountability Act (HIPAA), I acknowledge that a Notice of Privacy Practices was made available to me by Mountain View Eye Center

Assignment of Benefits & Financial Policy

I hereby authorize all medical, vision, and/or surgical benefits to which I am entitled through my Insurance carrier(s). (Including Medicare, Medicaid, private insurance, and any other health/medical/vision plan(s)) to be paid directly to Mountain View Eye Center. I understand that I am financially responsible for any co-pay, eoinsurance, deductible, and non-covered service(s). I hereby authorize Mountain View Eye Center to release any Information to my insurance carrier(s). including my diagnoses and treatment(s). This assignment will remain in effect until revoked, by me, in writing.

I hereby consent to receiving manually dialed and auto-dialed calls (which may Include artificial or pre-recorded collection or healthcare related messages) to my wireless/cellular number and/or any other telephone numbers provided during any interaction, agreement, or communication with Mountain View Eye Center and/or Its affiliates and assignees, including but not limited to any account management/billing company(ies) or third-party collection agency(ies).

I agree that in the event that a payment is returned for NSF (non-sufficient funds), I authorize Mountain View Eye Center to charge me for the amount of the payment plus a minimum $35.00 processing fee. If payment in full is not made as required, then In addition to all other amounts that may be due, I agree to pay a collection fee of up to 40% of tile principal amount as provided by §12·1·11 of the Utah Code Annotated, and further agree to pay all other costs of collection (Whether incurred by Mountain View Eye Center or Its assignees) Including by not limited to court costs, reasonable attorney fees, and Interest (both pre- and post-Judgment) at the rate of 1.5% per month (18% per annum).

Appointment Cancellation/No Show Policy

Thank you for trusting your vision care to Mountain View Eye Center When you schedule an appointment with us, we set aside enough time to provide you with thorough, high quality care. Due to an uptick in patients not showing up for their scheduled appoinbnents, we find it necessary to implement a "No Show" policy. We have many patients on waiting lists, so out of respect to them and to accommodate them sooner, we want to minimize our no shows.

Should you need to cancel or reschedule an appointment, please contact our office as soon as possible and no later than 24 hours prior to your scheduled appointment. This gives us time to schedule another patient in that time slot from the waiting list.

Patients who fail to show or cancel/reschedule an appointment and have not contacted our office with at least 24 hours notice will be considered a No Show and charged a $25.00 fee. Appointments are held for 15 minutes after the scheduled arrival time before being labeled as a No Show.

This No Show fee is charged to the patient, not the insurance company, and is due at the time of the patient's next office visit

Patients who have three (3) or more No Show appointments may result in a termination of the practice/patient relationship.

As a courtesy, when time allows, we make reminder calls for appointments. If you do not receive a reminder call or message, the above policy will remain in effect

We understand there may be times when an unforeseen emergency occurs and you may not be able to keep your scheduled appointment. If you should experience extenuating circumstances, please contact our office at 801-773-2233. Should you need to contact us outside of regular business hours, you may leave a voicemail message or send a text message to our office phone number.

Please sign that you have read, understand and agree to the Appointment Cancellation/No Show Policy.

Patient Insurance Card

Please upload photos of both the FRONT and BACK of your insurance card using the button below.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.