If you are a new patient, please print the Patient Information Sheet and the New Patient Medical History Questionnaire form by clicking on the appropriate links. Please print clearly in ink and bring the completed forms with you when you come in for your appointment.
Also, please remember to bring your insurance card(s) and a list of your current medications. If your insurance requires a co pay, it will be your responsibility to pay that at the time of your visit.
- Patient Information Sheet
- New Patient Medical History Questionnaire
- Our Financial Policy
- HIPAA Patient Consent
- Medical Records Release Authorization
Note: These documents are in Adobe® PDF format and require Adobe Reader to be viewed. You can download Adobe Reader for free by clicking here.
If you are a returning patient but have not been to our office for more than three years, please let us know at the time you make your appointment. If may be necessary for you to complete forms prior to the time of your appointment.
You can save time and help us stay on schedule by bringing in your completed forms when you come in for your appointment.
Cochise Eye & Laser participates in many medical insurance plans -- Medicare, Tricare and Tricare for Life, Cigna, Aetna are just a few. We are also contracted with EyeMed, VSP and Spectera for vision insurance. If we are contracted with your insurance, we will file a claim on your behalf. Please contact your insurance company if you have any questions about your benefits or how your claim was paid.
Insurance often does not cover all necessary healthcare expenses. Financing is available via CareCredit. You can read more information about CareCredit at their website, www.carecredit.com.
Patient’s Bill of Rights
THE PATIENT HAS THE RIGHT…
- to be treated with respect, consideration and dignity including privacy in treatment.
- to receive services without regard to age, race, color, sexual orientation, religion, marital status, sex, national origin or sponsor.
- to be informed of the medical / surgical services available and of the provisions for off hour’s emergency coverage.
- to receive complete and current information concerning his / her diagnosis, treatment and prognosis in terms the patient can understand.
- to receive complete information necessary to give informed consent prior to the start of any procedure or treatment. The informed consent shall include the procedure, the possible risks and complications, the alternatives if there are any, in a language the patient can understand.
- to request treatment; however, you do not have the right to demand treatment deemed medically unnecessary or inappropriate.
- to refuse recommended treatment, to be fully informed of the medical consequences of refusing treatment, to refuse to participate in experimental research.
- to be informed of the charges for services, eligibility for third-party reimbursements, receive an itemized copy of his / her account statement upon request.
- to privacy and confidentiality of all patient information and records pertaining to his / her care, treatments and surgery.
- to approve or refuse the release or disclosure of the contents of his / her medical record to health care providers and/or health care facilities except as required by law or third party payment contracts.
- to access to his / her medical record.
- to voice concerns, complaints or make recommendations regarding office policies, procedures, services or care with your doctor, nurse, technician, receptionist or any staff member.
- to file a formal complaint / grievance regarding office policies, procedures, services or care with the facilities grievance officer without fear of reprisal. You may request to speak directly with the managers of the following departments: Receptionists/Patient Services; Financial Services; Medical Services; Surgical Services; Post-operative Care Services; Optical Services; Administrator.
- to file a formal complaint / grievance regarding office policies, procedures, services or care with the facilities grievance officer without fear of reprisal. For reporting in writing, the mailing address is: Cochise Eye & Laser, c/o Grievance Officer, 2445 East Wilcox Drive, Sierra Vista, AZ 85635. For reporting by phone: (520) 458-8131 ext 118. The grievance officer and appropriate managers will investigate the complaint and respond to the patient or patient’s designee in writing within 30 days. The written response or report will contain the results of the investigation along with the name of a contact person to call in regards to the report findings and resolution.
- to file a formal complaint / grievance with the State Department of Health Services regardless of whether you use the office grievance process, without fear of reprisal. The State Department of Health Services phone number is (520) 628-6965 or (877) 255-2212. Web site: www.azmd.gov. Mailing address: Arizona Medical Board, 9545 East. Double Tree Ranch Road, Scottsdale AZ 85258.
- to file a formal complaint/grievance with Medicare use the website: www.medicare.gov/ombudsman/resource.asp.