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North Texas Eye Center
4100 West Fifteenth Street – Suite 210
Plano, Texas 75093
972.867.7777
Lewis J. Frazee, M.D.
James A. Passmore, M.D.
Ellen Ngo, M.D.
CONSENT FOR USE AND DISCLOSURE
OF HEALTH INFORMATION
I hereby permit North Texas Eye Center to release and furnish all medical and
financial data related to my care that may be necessary now or in the future for purposes of
treatment, payment or health care operations to assist with, aid in, or to facilitate the
collection of data for the purposes of utilization review, quality assurance, or medical
outcomes evaluation purposes. Such information may be released to family members,
caregivers, insurance companies, HMOs and PPOs, managed care organizations, IPAs,
Medicare/Medicaid, or other governmental or third party payors, or any organizations
contracting with any of the above entities to perform such functions.
You have the right to request that this office restrict uses and disclosures of your
health information; however, this office is not required to agree to a requested restriction.
You have the right to revoke this consent in writing, except to the extent that this office has
previously taken action in reliance on this consent. Your treatment by this office is
conditional upon your signing this consent.
□ OK to leave voice mail message regarding medical information.
Additional authorization to release medical information to:
Patient’s name PRINTED
Patient’s signature
Witness’ name PRINTED
Witness’ signature
Date
North Texas Eye Center
4100 West Fifteenth Street – Suite 210
Plano, Texas 75093
972.867.7777
Lewis J. Frazee, M.D.
James A. Passmore, M.D.
Ellen Ngo, M.D.
I UNDERSTAND THAT I AM ULTIMATELY RESPONSIBLE FOR THE PAYMENT OF MY BILL AND THAT
ANY BALANCE UNPAID BY MEDICARE OR ANY OTHER INSURANCE COMPANY AT 60 DAYS AFTER SERVICE
IS DUE BY ME. FAILURE TO COMPLY MAY RESULT IN THE INVOLVEMENT OF A COLLECTION AGENCY.
THE ONLY EXCLUSIONS TO THIS POLICY ARE HEALTH MAINTENANCE ORGANIZATIONS (HMOs) OR
PREFERRED PROVIDER ORGANIZATIONS WHERE, EXCEPT FOR DEDUCTIBLES AND CO-PAYMENTS,
BALANCE BILLING IS PROHIBITED.
I AUTHORIZE ANY HOLDER OF MEDICAL AND/OR PERSONAL INFORMATION ABOUT ME TO
RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION OR ANY OTHER ORGANIZATION AND ITS
AGENTS ANY INFORMATION NEEDED TO DETERMINE BENEFITS OR TO AUDIT MY ACCOUNT.
I UNDERSTAND THAT BY SIGNING THIS FORM, I AM REQUESTING MY INSURANCE COMPANY TO
PAY CLAIMS DIRECTLY TO THIS OFFICE. I ALSO UNDERSTAND THAT MY SIGNATURE AUTHORIZES
RELEASE OF ANY MEDICAL INFORMATION NECESSARY TO PAY THE CLAIM.
IF OTHER HEALTH
INSURANCE IS INDICATED ON HCFA 1500 FORM OR ON ELECTRONICALLY SUBMITTED CLAIMS, MY
SIGNATURE AUTHORIZES THE RELEASE OF THE INFORMATION TO THE INSURER OR AGENCY SHOWN.
I UNDERSTAND THAT I WILL NOT GET A CONTACT LENS PRESCRIPTION WITH A ROUTINE EYE
EXAMINATION. I UNDERSTAND THAT I MUST UNDERGO A CONTACT LENS FITTING IN ORDER TO OBTAIN
A CONTACT LENS PRESCRIPTION. I UNDERSTAND THAT THERE IS AN ADDITIONAL CHARGE FOR A
CONTACT LENS FITTING. FURTHERMORE, I UNDERSTAND THAT I MUST KEEP THE CONTAINER IN WHICH
MY CONTACT LENSES WERE DELIVERED TO ME AS DOCTOR FRAZEE, SWANSON OR PASSMORE CANNOT
RETURN ANY DEFECTIVE CONTACT LENS WITHOUT IT.
I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF FEES FOR ANY SPECIALIZED TEST
REQUESTED BY MY PHYSICIAN FOR DIAGNOSTIC PURPOSES IF MY MEDICARE OR INSURANCE COMPANY
DENIES PAYMENT OF SUCH DIAGNOSTIC TEST FOR ANY REASON.
I ACCEPT TOTAL RESPONSIBILITY FOR ANY AND ALL REFERRALS THAT MAY BE REQUIRED FOR
ANY VISIT TO THIS DOCTORS OFFICE. ADDITIONALLY, I HEREBY WAIVE ALL INDEMNITY FROM THIS
RESPONSIBILITY THAT MAY OTHERWISE BE AFFORDED ME BY MY INSURANCE CARRIERS. ACCORDINGLY,
I AGREE TO PAY FOR ALL CHARGES NOT COVERED BY MY INSURANCE CARRIERS RELATING TO ABSENT,
INCORRECT, IMPROPER, EXPIRED OR OTHERWISE UNACCEPTABLE REFERRALS.
Patient’s name PRINTED
Patient’s signature
Witness’ name PRINTED
Witness’ signature
Date
MEDICAL HISTORY FORM
Please take a few minutes to fill out this medical history form. We are required by Medicare and insurance companies to keep this
information in your file and to update it on a regular basis. Thank you for your cooperation.
PLEASE PRINT
Who is your primary care physician?
If you have a rheumatologist, who is it?
If you have an endocrinologist, who is it?
Who referred you to the office today?
List all ALLERGIES TO MEDICATIONS:
\
List all CURRENT MEDICATIONS:
List all CURRENT AND PAST DISEASES/CONDITIONS (Include conditions for EVERY CURRENT MEDICATION):
FAMILY MEDICAL HISTORY:
Glaucoma
High blood pressure
Diabetes
Rheumatoid Arthritis
Macular Degeneration
(circle the correct response):
yes
yes
yes
yes
yes
no
no
no
no
no
List all past EYE SURGERIES:
SOCIAL HISTORY (circle the correct response):
Married
Single
Divorced
Separated
Widowed
Do you drink alcohol
Do you use tobacco products
Have you used illegal drugs at any time
yes
yes
yes
yes
yes
yes
yes
yes
no
no
no
no
no
no
no
no