I hereby authorize employees and agents of Tylock-George Eye Care (including physicians, physician assistants and nurse practitioners and other employees and staff members) to render medical evaluations and care to the patient indicated below. I understand that by not signing this consent, the patient will not be provided medical care except in a case of emergency.
List all of the medications that you take routinely or that are prescribed for you by a doctor. (Include vitamins, over the counter medications, eye drops, herbal medications, birth control, hormones, etc.)
If you need further space, continue with medications list in the textbox below
I hereby authorize payment of medical benefits directly to Tylock-George Eye Care and/or the attending physician for services rendered. Authorization is hereby granted to release information contained in the patient's medical record to the patient's medical insurance company (or its employees or agents) as may be necessary to process and complete the patient's medical insurance claim. I understand that this authorization may include release of information regarding communicable diseases, such as Acquired Immune Deficiency Syndrome ("AIDS") and Human Immunodeficiency Virus ("HIV"). I understand that I am financially responsible for the total charges for services rendered which may include services not covered by the patient's insurance companies. I agree that all amounts are due upon request and are payable to Tylock-George Eye Care. I further understand that should my account become delinquent, I shall pay the reasonable attorney fees or collection expenses of Tylock-George Eye Care, if any.
The duration of this authorization is indefinite and continues until revoked in writing. I understand that by not signing this release of information, I am responsible for payment of services in full before the services are rendered.
The Health Insurance Portability and Accountability Act (HIPAA) is a federal government regulation designed to ensure that you are aware of your privacy rights and of how your medical information can be used by our staff in providing and arranging your medical care.
Tylock-George Eye Care is furnishing you with the attached notice, which provides information about how Tylock-George Eye Care and its physicians' may use and/or disclose protected health information about you for treatment, payment, health care operations and as otherwise allowed by law.
By signing this form, you acknowledge that you have received a copy of Tylock-George Eye Care's Notice of Health Information Practices.
Electronic Communication Disclosure: Tylock-George Eye Care E-mail Guidelines
Confidentiality and Privacy
Consent and Agreement
I have carefully reviewed this document and agree to fully comply with the guidelines defined herein for electronic communication from TGEC. I understand that the service will be offered at no charge and that I will be notified if and when a fee is administered for the service.
Tylock-George Eye Care is implementing a systematic method of collecting data on race, ethnicity, and communication needs directly from patients or their caregivers. The purpose of collecting this information is to ensure that all patients receive high-quality care.
We would like for you to provide us with your race and ethnic background. We will only use this information to review the treatment patients receive and make sure everyone gets the highest quality of care.
Race Definitions: American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Black or African American: A person having origins in any of the black racial groups of Africa. White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. Multiracial A person having more than one or a combination of the above origins
Keeping our patient's information private is important to us and by default we will only disclose information related to the patient's Billing Account and Medical Conditions to the patient or legal guardian.
If you would like to add additional contacts (other than the patient or legal guardian) that Tylock-George Eye Care is allowed to disclose this type of information to, please complete the fields below and select the appropriate checkboxes based on your approval for each person you list. In addition, please choose the person you would like Tylock-George Eye Care to list as your Emergency Contact in the event an emergency situation was to take place at our office.
The duration of this authorization is indefinite unless otherwise revoked in writing. I understand that requests for health information from persons not listed on this form will require my specific authorization prior to the disclosure of any health information.
Our goal is to provide quality individualized medical care in a timely manner. "No-shows" and late cancellations inconvenience those individuals who need access to medical care in a timely manner. We would like to remind you of our office policy regarding missed appointments. This policy enables us to better utilize available appointments for our patients in need of medical care.
A "no-show" is someone who misses an appointment without cancelling it in an adequate manner. A failure to be present at the time of a scheduled appointment will be recorded in your medical record as a "no-show." If you are a one-day post op LASIK patient you will be considered a “No Show” if you are more than 15 minutes late for your post op appointment and you may need to reschedule your appointment.
In order to be respectful of the medical needs of other patients, please be courteous and call the Tylock-George Eye Care office promptly if you are unable to show up for an appointment. This time will be reallocated to someone who is in need of treatment. If it is necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Your early cancellation will give another person the possibility to have access to timely medical care.
To cancel appointments, please call 972-258-6400. If you would like to reschedule your appointment our office staff can reschedule it for you during the call. If you are calling after hours you will need to call back during regular business hours to reschedule.
A late cancellation is considered when a patient fails to cancel their scheduled appointment with a 24-hour advance notice.