Date SSN: DOB: Patient Name. Address

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1 IRMO EYE CENTER PATIENT INFORMATION Date SSN: DOB: Patient Name Address (Street) (City) (State) (Zip) Home Telephone Cell Phone Sex: M F Marital Status: Married Divorced Widowed Separated Single Employment Status: Full time Part time Retired Unemployed Employer/School Name Work Phone # INSURANCE INFORMATION Primary Medical Insurance: Name ID# Name of Insured DOB: Employer of Insured Work # SSN of Insured (if different from above) Relationship of the Patient to Insured (Please continue to the next page)

2 Secondary Medical Insurance: Name ID# Name of Insured DOB: Employer of Insured Work # SSN of Insured (if different from above) Relationship of the Patient to Insured Routine Vision Insurance: Name ID# Name of Insured DOB: Employer of Insured Work # SSN of Insured (if different from above) If you fail to cancel, reschedule, or just no-show without giving our office a 24 hour notice on 2 occasions, a fee may be added to your account. (Please continue to the next page)

3 INSURANCE/BILLING POLICIES MEDICAL INSURANCE: Your insurance policy/policies are a contract between you and your insurance company. It is your responsibility to know your benefits, limitations, out of pocket copayments, deductibles and co-insurance amounts. We participate with many insurance plans and will file a claim for our services as a courtesy. If your health plan determines a service to be not covered or you fail to provide the correct insurance information at the time of your visit, you will be responsible for the complete charge. If you have insurance with a plan we do not participate with, we will require full payment at the time of service. It is your responsibility to notify the front office staff of any insurance additions or changes. Fraud laws prohibit us from changing your procedures and/or diagnosis codes after the service is rendered just to get the claim paid. We make every effort to code and file claims accurately according to the services rendered by the physician and documentation in your medical record. ROUTINE VISION INSURANCE: This insurance will cover routine screening eye exam and determination of your glasses prescription (refraction). If a medical eye problem is found and needs to be addressed during a routine visit, a separate charge will be made and filed with your medical insurance. If you determine that you have vision insurance after the date of service and we have to correct this and file a claim, there will be a $30.00 fee. REFRACTION: Your examination may include a refraction which is the part of the examination to determine your glasses prescription. Most insurance companies do not cover the refraction regardless of your diagnosis. If you have a refraction as part of your exam, you will be responsible for the charge of $35.00 along with any other expenses that are deemed to be your responsibility, at the time of service. A refraction may be required to determine if a visual problem is due to a refractive error or a medical eye problem. CONTACT LENSES: A contact lens fitting is required for the physician to determine the correct contact lens to prescribe. There is a fee for the fitting and most insurance plans do not pay this fee so you will be responsible for this fee at the time of service, along with any other services that are deemed to be your responsibility. The fees are as follows: Initial fit: $89.00 Annual update: $35.00 Contact lens change: $45.00 Contact lenses will be dispensed or ordered once full payment is received. (Please continue to the next page)

4 OPTICAL: If you have no routine vision coverage, glasses and/or sunglass orders will be sent to the lab after 1/2 of the total is paid. The remaining balance must be paid at the time the glasses/sunglasses are picked up. Any glasses orders cancelled after the order is placed with the lab, will require a $50.00 restocking fee. If you have routine vision coverage, you will be responsible for paying your portion, per your insurance plan, at the time the glasses are ordered. DMV RENEWALS: Our physician will be happy to complete the vision portion of your SC Department of Public Safety Driver s License Renewal form as follows: Form completed during a scheduled office visit: No charge At any time after the visit: $10.00 (due and payable prior to release of this form) If it has been over a year you will need to come in and have the technicians check your vision without seeing the physician: $28.00 (due and payable at the time of service) Please allow a 24 hour turnaround time for forms dropped off at any time after the visit. MEDICAL INSURANCE/DISABILITY FORMS: There is a $25.00 fee for completion of all medical/disability forms. Please allow 2 business days for these forms to be completed. Payment must be made prior to the release of the form. MEDICAL RECORDS RELEASE: After a medical record release form is signed, we will be happy to send your medical records to another physician up to 10 pages, at no charge. If you request to receive records, a fee of.65 cents for the first 10 pages and.50 cents per page thereafter, along with a research/copy fee of $ This must be paid prior to the copying of the records. RELEASE OF INFORMATION: I hereby authorize Irmo Eye Center to furnish and disclose all known facts concerning my care to my insurance company and to other physicians at my request. I am aware of and have access at any time, to the Notice of Privacy Practices HIPAA regulations located in this office. ASSIGNMENT OF BENEFITS: I hereby authorize all insurance companies to make payments directly to Irmo Eye Center for any insurance benefits for professional services rendered. I understand that I am responsible for any charges not paid by my insurance company. I HAVE READ THIS DOCUMENT AND UNDERSTAND THE ABOVE POLICIES. Signature Date

5 ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES I acknowledge that I have been given the opportunity to review Irmo Eye Center s Notice of Privacy Practices: It tells me how Irmo Eye Center will use my health information for the purposes of my treatment, payment for my treatment, and Irmo Eye Center s health care operations. The Notice explains in more detail how Irmo Eye Center may use and share my health information for other than treatment, payment and health care operations. Irmo Eye Center will also use and share my health information as required/permitted by law. Signature: (Patient or legal representative) Date:

6 IRMO EYE CENTER PATIENT REVIEW OF SYSTEMS/MEDICAL HISTORY PATIENT NAME: DOB: DATE: EMERGENCY CONTACT NAME: PRIMARY CARE PHYSICIAN: PHONE: REFERRING PHYSICIAN: OCULAR HISTORY - PATIENT PLEASE CHECK THOSE THAT APPLY: EYE PAIN/IRRITATION RED EYES LOSS OF VISION/BLURRY DRYNESS/SANDY/GRITTY ITCHING FLOATERS/FLASHES DOUBLE VISION CATARACT CATARACT SURGERY TEARING HALOS/GLARE LAZY EYE GLAUCOMA DISCHARGE EYE INJURY MEDICAL HISTORY PATIENT MACULAR DEGENERATION GLASSES CONTACTS EYE DISEASE EYE SURGERY CROSSED EYES LASIK/PRK OTHER PLEASE CHECK THOSE THAT APPLY: HIGH BLOOD PRESSURE HEART FAILURE TYPHOID DISEASE HEART DISEASE HIGH CHOLESTEROL OTHER HEART ATTACK PACEMAKER/DEFIBRILLATOR ARRYTHMIA CAROTOID DISEASE HEART SURGERY HEART VALVE DISORDER HEART MURMUR PERIPHERAL VASCULAR DISEASE DIABETES # OF YEARS: CONTROLLED BY: INSULIN PILL DIET STROKE WHEN: DEFECTS: TIA/MINI STROKES SEIZURES BLOOD DISORDERS ANEMIA OTHER PNEUMONIA ASTHMA/EMPHYSEMA/COPD FEVER/WEIGHT LOSS SINUS PROBLEMS ON BIRTH CONTROLL PREGNANT/NURSING HIV TUBERCULOSIS/TB HEPATITIS LIVER DISEASE CICKLE CELL TRAIT KEDNEY FAILURE/DIALYISIS KEDNEY DISEASE ARTHRITIS/RHEUMATOID/LUPUS CANCER TYPE MIGRAINES PHYCHIATRIC TREATMENT HEADACHES MULTIPLE SCELEROSIS DEMENTIA/ALZHEIMERS ANXIETY DEPRESION ALLERGIES NONE 4/15

7 MEDICAL HISTORY- FAMILY GLAUCO BLINDNESS RETINAL DETACHMENT MUSCULAR DEGENERATION OTHER FAMILY OR PERSONAL HISTORY OF PROBLEMS WITH ANESTHESIA LAZY EYE CURRENT MEDICATION MEDICINE NAME OR (PROVIDE A COPY)/HOSPITALIATION AND YEAR PHARMACY INFORMATION PHARMACY NAME AND STREET ADDRESS: PHONE NUMBER: PREVIOUS SURGERIES/HOSPITALIZATIONS PLEASE PROVIDE TYPE OF SURGERIES/HOSPITALIZATION AND YEAR WHAT IS YOUR SMOKING HISTORY? SOCIAL HISTORY CURRENTLY NEVER FORMALLY WHAT IS YOUR ALCHOHOL USE HISTORY? DKRINK ALCHOHOL: YES NO IF YES, HOW MUCH? WHAT IS YOUR OCCUPATION? MD SIGNATURE DATE MD SIGNATURE MD SIGNATURE REVEW DATE REVEW DATE