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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Welcome to Our Office Please fill in the following information to help us provide you with optimum care: Today's Date Date of Birth Last Name SS# Address: Home Phone M/F Age First Name MI Spouse or Guardian : City State Work Phone Zip Code Cell Phone: Occupation: Email address: Preferred Language Race Ethnicity Emergency Contact: Name: Relationship: Phone: How did you hear about our office? Friend/family member (name) Yellow Pages Internet site Insurance Plan Other Referral Patient Medical and Eye History What health concerns or problems do you have regarding your eyes today? (Circle all that apply) Dryness Pain Redness Itch Lid Droop Watery Light Sensitivity Glare Blur Strain Irritation Haze Family History of Eye Disease Other___________________________________________________________________________________________ Date of last eye exam____________________ By whom? ________________________________________________ Do you currently wear contact lenses? No Yes Type: ______________________________________________ Have you ever been diagnosed with or treated for the following? (Circle all that apply) Cataracts Corneal Abrasion Dry Eye Eye Injury Iritis/Uveitis Macular Degeneration Lazy Eye Retinal Detachment Eye Infection Eye Allergies Diabetic Eye Disease Glaucoma Other Eye Disorders (list)______________________________________________________________________________________ CURRENT MEDICATIONS (Rx or over the counter) List medications including eye drops, vitamins & contraceptives. __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Allergies to medication: (please list) ___________________________________________________________________________ Are you currently pregnant or nursing? _______ Are you a smoker? ______ pk/day Drink alcohol? _______ drinks / day Have you ever been diagnosed with or treated for the following? (Circle all that apply) Allergies Anemia Arthritis Asthma Epilepsy Developmental Disabilities Heart Disease Fibromyalgia Colitis Depression Diabetes Panic/Anxiety Disorder Thyroid Leukemia Lupus Weight Loss High Blood Pressure Muscular Dystrophy Multiple Sclerosis Cancer (type) ______________________________________________________________________________ Name of family physician/practitioner: ______________________________________ Date of Last Visit ______________ Family Medical and Eye Health History Please circle all the following medical health conditions that have occurred in your family: Cataracts Corneal Problems Diabetes Macular Degeneration Heart Disease High Blood Pressure Glaucoma Retinal Detachment/Disease Other _____________________________________________________________________________________________________ 1/2014 Financial Policy / Insurance Information We ask that all patients read and sign our Financial Policy prior to seeing the doctor. 1.Payments and all co-payments are due at the time of service. Please indicate your preferred method of payment today. Check / Cash MasterCard / VISA American Express Discover Card 2.With insurances that require a referral, our office must have the referral prior to the appointment, or you will be charged for the exam at the time of service. We will assist you in obtaining the referral or authorization needed for services, but a referral or authorization, once obtained, does not guarantee payment to this office. You will be responsible for all charges that are not covered by your insurance due to co-payments or deductibles. 3.There are no refunds for examinations / treatment services or material purchases. 4.There will be a $30.00 fee for all returned checks, and balances older than 45 days may be subject to additional collection fees and interest. About Your Insurance There are two types of health insurance that will help pay for your eye care services and products. You may have both and our practice accepts both: 1. Vision Care plans (such as VSP, Davis, Spectera, Avesis, etc) 2. Medical insurance (such as Blue Cross Blue Shield, Presbyterian, Lovelace and Medicare) Vision care plans only cover routine vision exams along with eyeglasses and contact lenses. Vision plans over a basic screening for eye disease. They do not cover diagnosis, management or treatment of eye diseases. Medical insurance must be used if you have any eye health problem or systemic health problem that is associated with ocular complications. Your doctor will determine if these conditions apply to you, bust some are determined by your case history. If you have both types of insurance plans it may be necessary for us to bill some services to one plan and other services to the other. We will use coordination of benefits to do this properly and to minimize your outof-pocket expense. We will bill your insurance plan for services if we are a participating provider for that plan. We will try to obtain advanced authorization of your insurance benefits so we can tell you what is covered. If some fees are not paid by your plan, we will bill you for any unpaid deductibles, co-pay or non-covered services as allowed by the insurance contract. I, the undersigned, have read and agree to the above policies. Signature: Patient (Parent or Guardian if minor) Medical Insurance: Date: Vision Insurance: Assignment and Release: I hereby authorize third party or insurance payments to be made directly to Accent on Vision and fully understand that I am the responsible party for all fees incurred by me at the above mentioned facility. I also authorize the release of any information required for the processing of those claims. I, the undersigned, have read and agree to the above policies. Patient’s signature Date Reviewed: signature: Date: BRING YOUR INSURANCE CARD TO THE FRONT DESK If you are a new patient seeing us for a medical eye problem, we need a copy of your insurance card prior to your visit. If do not have it with you, we can reschedule your appointment or you can handle the fees personally today 1/2014 Practice’s Requirements The Practice: (a) Is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI. (b) Under the Privacy Rule, may be required by State law to grant greater access or maintain greater restrictions on the use or release of your PHI than that which is provided for under federal law. (c) Is required to abide by the terms of this Privacy Notice. (d) Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of your PHI that it maintains. (e) Will distribute any revised Privacy Notice to you prior to implementation. (f) Will not retaliate against you for filing a complaint. Effective Date This Notice is in effect as of 04/15/03. PATIENT ACKNOWLEDGEMENT By subscribing my name below, I acknowledge receipt of a copy of this Notice, and my understanding and my agreement to its terms. _____________________________ Patient Date 1/2014 1/2014