New Patients

Patient Information

* required

State *

Gender *

May we leave test results, medical information or medication information on your personal voice mail or answering machine? *

Preferred Language *

Race *


Ethnicity *

Responsible party or caregiver information

By naming a responsible party and/or caregiver you are authorizing Northwest Eye Clinic, Ltd. to share billing & medical information with them.

Power of Attorney

Please provide referring physician and/or primary care physician name(s) and phone number(s).

Medical Information

Please list the following as best you can.

Social History

Have you ever smoked? *

If yes, do you currently smoke? *

Pharmacy Information

Drink Alcohol?

How much?

Have you had any of the following problems or symptoms? *


Policy for Northwest Eye Clinic, Ltd.

By signing below I understand that my medical claims may not be covered in full by my insurance company and I will be responsible for any balance. Routine eye care, eyeglasses, contact lenses, refraction’s, and routine examinations are not covered by medical insurance. In the event that I am an HMO patient and do not bring a referral for services provided by Northwest Eye Clinic, Ltd., I understand that I am responsible for any charges incurred. In the event my account balance becomes past due I understand there may be a late charge of 5% per billing cycle. Northwest Eye Clinic, Ltd. has financing and payment options at 0% financing available in the event payment cannot be promptly made, in the event financing or a payment agreement is made with Northwest Eye Clinic, Ltd. no late charges will apply. In the event my account is placed into collection Northwest Eye Clinic, Ltd. shall be entitled to recover all reasonable collection fees.

Any request for medical records must be in writing, three to five days prior to receiving the records, charges for records may vary.

I have read and understand the above policy for Northwest Eye Clinic, Ltd.

Assignment of Benefits

I hereby instruct and direct * and/or Insurance Company(s) to pay by check or direct deposit made out to: Northwest Eye Clinic, Ltd. - Phone: (847) 296-4020 1400 E. Golf Road, Suite 212 - Des Plaines, IL 60016 for the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional service charges over and above this insurance payment.

A photocopy of this Assignment shall be considered as effective and valid as the original.

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this case, to determine these benefits or the benefits payable for related services.

I authorize my doctor to initiate a complaint to the Insurance Commissioner on my behalf.

Notice of Privacy Practice


Our commitment here at Northwest Eye Clinic, Ltd. is to serve our customers with professionalism and care, being sure at all times to protect the privacy and security of all Protected Health Information.

During the course of serving your interests it may be necessary to share information with other health care providers or business associates. The following are examples of instances where this information can and will be shared:

  • To conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • During treatment, we may find it necessary to acquire a laboratory analysis.
  • Obtain payment from third-party payers, Insurance Companies, and billing services.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

We at Northwest Eye Clinic, Ltd. are committed to obeying all Federal, State and Local laws and regulations regarding Privacy Practices. If any other uses or disclosures than the ones listed above are needed, information will only be released with the written authorization of the individual in question. This written authorization may be revoked at any time by the individual, as provided by law. If you have any questions or comments regarding your Protected Health Information, feel free to contact out office at (847) 296-4020.

I understand that, under the Health Insurance Portability & Accountability Act (“HIPPA”), I have certain rights to privacy regarding my Protected Health Information. I have received, read and understood your Notice of Privacy Practices. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you may restrict how my private information is used or disclosed to carry out treatment, payment or health operations. I also understand you are not required to agree to my requested restrictions but if you do agree then you are bound to abide by such restrictions.