Download comprehensive eyecare physicians

COMPREHENSIVE EYECARE PHYSICIANS
(PLEASE PRINT—Complete and accurate information will allow us to serve you better)
Date ______________________________
____ New Patient
____ Change of Information
Name (Last, First) ________________________________________________________________________
Street _________________________________________________________________________________
City______________________________________ State _______________ ZIP _____________________
Home Phone ___________________ Cell Phone ___________________ Work Phone__________________
Birthdate _________________________________
Gender:
Male
Female
Email Address _________________________________ Social Security Number ______________________
Would you be interested in receiving educational information from your doctor via email?
YES
NO
Would you be interested in receiving promotional eyecare discount offers via email?
YES
NO
Marital Status:
Single
Married
Divorced
Widowed
Insured Person’s Employer_______________________________ Employer Phone ___________________
Insurance Company Name _________________________________________________________________
Policy Holder Name ______________________________________________________________________
Patient Relation to Insured _________________________ Policy Holder Birthdate ____________________
Primary (or referring) Physican ______________________________________________________________
(referrals are required for HMO plans, most PPO plans, and all Medicare consultations)
Secondary Insurance Company Name ________________________________________________________
Secondary Policy Holder Name _____________________________________________________________
Patient Relation to Insured _________________________ Policy Holder Birthdate ____________________
Emergency Contact ______________________________ Phone Number ___________________________
(Revised 8/2012)
Verification that the information above is correct
Date: _________ Initial: ______
Date: _________ Initial: ______
Date: _________ Initial: ______
Date: _________ Initial: ______
Date: _________ Initial: ______
Date: _________ Initial: ______
Date: _________ Initial: ______
Date: _________ Initial: ______
Date: _________ Initial: ______
NEW PATIENT MEDICAL HISTORY
Date: ________________
Name (Last, First) _________________________________________________________________
Birthdate: _________________________
Gender:
Male
Female
Occupation: _____________________________________________________________________
PAST OCULAR HISTORY:
Have you had: (please circle)
Laser eye surgery:
Surgery for either eye:
Eye injury:
Eye infection:
NO
NO
NO
NO
Explanation
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
REVIEW OF SYSTEMS—Please explain all “yes” answers
Have you had problems with: (please circle)
Fever, weight loss, fatigue
NO
Rashes/other skin problems
NO
Head trauma
NO
Headache
NO
Ears, nose, or throat
NO
Neck pain/surgery
NO
Lungs/breathing
NO
Cardiovascular:
Heart disease
NO
High blood pressure
NO
Stomach/intestines
NO
Liver disease
NO
Kidney, bladder, genital
NO
Bones/arthritis
NO
Neurologic problems/stroke
NO
Lymphatic system
NO
Bleeding disorder
NO
Psychiatric disorder
NO
Diabetes
NO
Thyroid problems
NO
Other
NO
Are you pregnant
NO
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
YES How many years?______________________
YES ______________________________________
YES ______________________________________
YES ______________________________________
MEDICATIONS:
Eyedrops:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Prescription Medication:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
ALLERGY HISTORY:
Medication Allergies?
NO
Allergy to iodine or shellfish? NO
Explanation
YES ________________________________________
YES ________________________________________
FAMILY HISTORY:
Blindness
Glaucoma
Macular degeneration
Retinal detachment
NO
NO
NO
NO
Relationship to Patient
YES ________________________________________
YES ________________________________________
YES ________________________________________
YES ________________________________________
SOCIAL HISTORY:
Cigarette smoker? (please circle)
Alcohol? (please circle)
Never
None/rare
Current
<1 drink/day
Former, but stopped
>1 drink/day
PLEASE DO NOT WRITE BELOW THIS LINE
________________________________________________________________________________
The above history has been confirmed and discussed by me with the patient
_____________________________________________________, M.D.
Revised 8/2012
COMPREHENSIVE EYECARE PHYSICIANS
Financial Policy
Thank you for choosing Comprehensive Eyecare Physicians for your eyecare needs. We are
happy to serve you, and look forward to a long relationship with you, our valued patient. In an
effort to serve you efficiently, we have instituted the following financial policy. The policy below
outlines the understanding between you, the patient, and our office. Our office will, as a courtesy, file your insurance claims based upon the information you provided on your registration
sheet; however, it is your responsibility to provide us with complete and accurate information.
You will be asked to provide this information on an annual basis. Failure to provide information
necessary and required by the insurance company will result in the denial of your claim. Insured
parties are expected to know their plan requirements and to abide by any specifications of their
insurance plan. Furthermore, if information is requested from you, by the insurance company,
you must provide that information promptly. If your claim is denied, it becomes your responsibility to pay the balance in full. By signing below, you understand that you will be responsible for
the payment of any services not paid by the insurance company which includes co-payments,
deductibles, coinsurance, and non-covered services and denied services not covered by contract
by our office and your insurer.
We will assist you in any way possible to be sure the claim is handled properly; we will file your
insurance claim for you, and send a reminder statement when there is a balance to be paid by
you. In instances where it is deemed necessary, we reserve the right to refer uncollected balances to an outside collection agency.
By keeping open lines of communication and by providing accurate information, you can be sure
your claims will be handled promptly and efficiently.
Thank you in advance for your cooperation.
By signing below, I agree that I am ultimately responsible for payment of services provided to
me. My signature below authorizes Comprehensive Eyecare Physicians to release the information necessary to facilitate the payment of medical claims.
Signature _____________________________________________________________________
Date _________________________________________________________________________
(revised 8/2012)