Welcome to Florida Eye Institute!
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- Owen Cannon
- 5 years ago
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1 Welcome to Florida Eye Institute! We look forward to greeting you as a new patient. Having served the Vero Beach community for over 30 years, it is our steadfast goal to help you achieve the best vision possible while receiving the best personalized care. As a multi-specialty ophthalmology practice we offer the latest advances in cataract surgery, glaucoma treatment, macular degeneration and diabetic eye conditions; as well as general ophthalmic care, low vision evaluation and rehabilitation, laser vision correction, and expert fitting of glasses and contacts; all within one comprehensive medical and surgical facility. Enclosed are several important forms for you to review Medical History, New Patient Information and Financial Policy. Please complete and bring to your appointment along with current medications (including eye drops), eyeglasses, and insurance identification. Expect your appointment to last approximately 90 minutes. For your convenience we offer free Wi-Fi service, coffee and refreshments. Following your exam and eye dilation you may experience difficulty driving or reading for several hours; please bring sunglasses to protect your eyes and consider having a driver if your eyes are particularly sensitive. Should you have any questions about your appointment or our services; please call Estefani Jaimes, Scheduling Supervisor (772) See you soon! Staff and Physicians of Florida Eye Institute
2 FLORIDA EYE INSTITUTE NEW PATIENT INFORMATION FORM Patient Name: Local Address: City / State / Zip Alternative Address: City / State / Zip What months are you at your alternative address? From To Local Phone: Alternate Phone: Cellular Phone: Address: Patient Employer: Employer Phone: Patient DOB: Sex: M F Patient SS#: Emergency Contact Name: Marital Status: Emergency Contact Phone: Spouses Name: Spouses DOB: (If Minor) Parent Name: DOB: Daytime Phone: INSURANCE INFORMATION - Please give cards to receptionist to make copies. Thank you. WHICH DOCTOR ARE YOU HERE TO SEE: (please circle one) Thomas A. Baudo, M.D. Karen D. Todd, M.D. Val Zudans, M.D. Wilson K. Wallace, M.D. Cynthia L. Kipp, O.D. Christopher Shumake, M.D. Other How did you hear about us? Please include names. Patient Family Member Referred by M.D. Optometrist Newspaper - Name Radio - Station Name Insurance Company Seminar Our Website Senior Services Guide Yellow Pages Other - Please Specify Please indicate the reason for your visit. Routine Eye Exam Diabetic Exam Interest in Laser Vision Correction Cataract Check Glaucoma Check Need New Glasses Having a Problem - Medical Other Account Number: Contact Lenses DO NOT WRITE IN THE BOX BELOW - FOR OFFICE USE ONLY Date Registered: Registered By:
3 FINANCIAL POLICY We are pleased to have you as our patient, and we are committed to providing you with our best professional care. Your understanding of our Financial Policy is important to our relationship. Please ask us if you have any questions. INSURANCE Due to all the various insurance plans now in effect, we require that you check with your insurance carrier(s) regarding our participation in your specific network. There are instances when even though we are contracted with a carrier, the carrier has networks in which we do not participate. If our offices does not participate in your network, you will be responsible for a large portion of or the entire bill. The carrier contract information is located on the back of your insurance card. It is your responsibility to update us with any new card that you receive from your carrier. Some insurance plans require an authorization for services in our office. It is your responsibility to acquire the appropriate paperwork. If the visit is not authorized, you will be responsible for the cost of services. We will send your insurance carriers(s) a claim for all services provided. You will be billed for any balance due after the carrier settles your claim. PAYMENT EXPECTATIONS If you are not covered by insurance, you will be required to pay for your services on the date the service is required. All patients are required to pay co-payments, deductibles and co-insurance at the time of your visit. You will receive a statement from our office after your insurance has settled your claim if there is any balance due. Payments are expected within thirty dates of receipt of the statement. Our office accepts cash, checks and VISA/MasterCard/Discover.
4 PATIENT AUTHORIZATION I hereby authorize that payment from my medical insurance program or my Medicare benefits be made directly to Florida Eye Institute, PA and Florida Eye Institute Surgicenter, LLC for any unpaid bills for services provided to me on or after today. I understand that I will be financially responsible for any balance not covered by my insurance carrier. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable for related services. This assignment shall remain in effect until revoked by me in writing. A photocopy of this assignment is considered as valid as the original. There will be a $25.00 charge for any returned checks. There will be a $35.00 charge for any account having to be placed with a collection agency. I have read and understand this policy. Signature Date
5 Patient Privacy Policy Use and Disclosure of Protected Health Information HIPPA By signing this Consent Form, you give us permission to use and disclose protected heath information about you for treatment, payment, and healthcare operations except for any restrictions specified below to which we have agreed. Protected health information is individually identifiable information we create or receive including demographic information relating to your physical or mental health in the provision of healthcare services to you and the collection of payment for providing healthcare services to you. Our Notice of Privacy Policies provides information about how we may use and disclose protected health information about you. If we change our Notice, you may obtain a revised copy by contacting our information privacy officer in writing: Florida Eye Institute Attention: Information Privacy Officer 2750 Indian River Boulevard Vero Beach, Florida If you choose not to sign this Consent Form, we have the right to refuse you treatment unless a licensed healthcare professional has determined that you require emergency treatment or we are required by law to treat you. We are required to document any circumstances in which we do not obtain your consent, yet carry out treatment. We will offer you copies of this documentation should you decide not to sign the Consent Form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent. You may request to use our Authorization for Release of Information for purposes of requesting action, or you may simply send us a letter in writing. By signing this consent, you acknowledge that you have been given the opportunity to read the Notice of Privacy Policies. Patient s Signature Date Print Name
6 History and Intake Form Name: Date: D.O.B Primary reason(s) for today s visit: Cataract Glaucoma Dry Eye Diabetes Macular Degeneration Blurred Vision Other: Past Medical History: (please circle all that apply) Anxiety Hypertension Arthritis HIV/AIDS Asthma Hypercholesterolemia Atrial fibrillation Hyperthyroidism BPH Hypothyroidism Bone Marrow Transplantation Leukemia Breast Cancer Lung Cancer Colon Cancer Lymphoma COPD Pacemaker Coronary Artery Disease Prostate Cancer Depression Radiation Treatment Diabetes Seizures GERD Stroke Hearing Loss Valve Replacement Hepatitis Past Surgical History: (please circle all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Breast Reduction Breast Implants Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass PTCA Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Kidney Biopsy (Right, Left) Kidney Removed (Right, Left) Kidney Stone Removal (Right, Left) Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Heart Stent 1
7 Past Surgical History continued: Joint Replacement, Knee (Right, Left, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Ocular History: (please circle all that apply) Allergic conjunctivitis Narrow Angles (Right eye, Left Blepharitis eye) Cataract (Right eye, Left eye) Ocular Hypertension Corneal dystrophy (Right eye, Left eye) Ophthalmic Migraine Diabetic retinopathy, background Retinal tear (Right eye, Left eye) (Right eye, Left eye) Retinal Detachment (Right eye, Dry eyes Left eye) Drusen (Right eye, Left eye) Soft/Hard Contact Lens Wearer Glaucoma (Right eye, Left eye) Strabismus Macular degeneration (Right eye, Left eye) Lazy Eye/Amblyopia Macular Pucker (wrinkle) (Right eye, Left eye) Floaters (Right eye, Left eye) Monovision Ocular Surgery: (please circle all that apply) Blepharoplasty (Right eye, Left eye) Ptosis repair Cataract surgery (Right eye, Left eye) Punctal Plugs (Right eye, Left eye) Corneal transplant (Right eye, Left eye) Strabismus Surgery DSAEK (Right eye, Left eye) Retinal Laser Eye Muscle Surgery Trabeculectomy Intravitreal injections (Right eye, Left eye) Tube Shunt (Right eye, Left eye) LASIK (Right eye, Left eye) Yag Capsulotomy (Right eye, Left Monovision (Right eye, Left eye) eye) PRK (Right eye, Left eye) Family History/Immediate family member only: (please circle all that apply) Blindness High blood pressure Cancer High cholesterol Cataracts Macular degeneration CVA/Stroke Migraine Diabetes Retinal Detachment Glaucoma Strabismus Heart Disease 2
8 Medications: (Please list all current prescription and over the counter medications) Please list dosage and frequency. Allergies: (Please enter all allergies) Please list reaction(s). Eye Drops: (Please list all over the counter and prescription drops, including frequency and eye(s). 3
9 Social History: (Please circle all that apply) Cigarette Smoking: Never smoked Quit: former smoker Smokes less than daily Smokes daily Alcohol Use: Alcohol: none Alcohol: less than 1 drink a day Alcohol: 1-2 drinks a day Alcohol: 3 or more drinks a day Safety: I feel safe at home. I do not feel safe at home. Review of Systems: Are you currently experiencing any of the following? (Please check all that apply) Symptom Poor Vision Eye Pain Tearing Redness Loss of Vision High blood pressure Rapid Heart Rate Diabetes Thyroid Abnormalities Chills Ear Ache Dry Mouth Shortness of breath Upset Stomach Constipation Incontinence Joint Pain Arthritis Headache Depression Weakness Head Injury Decreased Hearing Other Symptoms: 4
10 Alerts: Have you ever or are you currently experiencing any of the following? (Please check all that apply for the following) Allergy to Lidocaine Allergy to Adhesive Artificial heart valve Blood thinners Defibrillator Flomax MRSA Narrow Angles Pacemaker Rapid heartbeat with epinephrine Steroid Responder Other Symptoms: Refraction Fee: Refraction is the measurement of glasses prescription for the purpose of prescribing new glasses or determining the best-corrected visual potential of the eye. Medicare and many private medical insurance programs do not cover this service and require a separate charge apart from the medical part of the exam. Some supplemental insurance will reimburse this fee. You will need to contact your insurance company to find out if and how they cover this service. You will be given a receipt if this service is performed. The refraction fee is $40. I have read and understand the refraction policy. Patient s Signature: Date: [ ] History reviewed [ ] No changes [ ] Additions as noted Technician Initials: Physician s Signature: Date: 5
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Date. Cell Phone: ( )
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PATIENT REGISTRATION FORM. _Apt#:. _Apt#:.
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Minor Patient Information
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PATIENT INFORMATION. Patient s last name: First: Middle: Marital status:
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PATIENT INFORMATION SHEET. Reason(s) for Visit: (chief complaint)
PATIENT INFORMATION SHEET Patient : Pharmacy: Date of Birth: Pharmacy Phone Number: Reason(s) for Visit: (chief complaint) Past Medical History: (Check all that apply) Anxiety Arthritis Asthma Atrial Fibrillation
Greenbriar Vision Center Welcomes You Please Print Clearly
Greenbriar Vision Center Welcomes You Please Print Clearly First Name Last Name Today s Date Address City State Zip Code Home # Work # Cell # Email Sex: Birth date: Age: Parent/Guardian s name (if patient
PATIENT REGISTRATION
PATIENT REGISTRATION PLEASE PRINT and be sure to complete the entire form and bring with you to your eye exam. Last Name First Name Middle Name Email Address Date of Birth Age Sex Home Address Street City
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam or surgical consultation today. All surgical consultations require a refraction in order to determine which vision correction procedure
Illinois Dermatology Institute
Illinois Dermatology Institute PATIENT INFORMATION (Please Print) Today s _/ / Name: Last First M.I. Mailing Address: Street City State Zip Code Home Phone ( ) Work Phone ( ) Cell Phone ( ) OK to leave
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a Complete Eye Exam or surgical consultation today. If you are here for your Eye examination and you are experiencing blurry vision or any visual changes,
PATIENT INFORMATION SHEET. Reason(s) for Visit: (chief complaint)
PATIENT INFORMATION SHEET Patient : Pharmacy: Date of Birth: Pharmacy Phone Number: Reason(s) for Visit: (chief complaint) Past Medical History: (Check all that apply) Anxiety Arthritis Asthma Atrial Fibrillation
Patient History Information Fill in all the blanks. Date and Sign on the back. Patient Information Name: (Last) (First) (Middle)
dba AND OPHTHALMOLOGY ASC, LLC and VAN DYCK ASC, LLC Date completed: Patient Information Name: (Last) (First) (Middle) Address: City: State: County: Zip Code: Sex: Race: Email: Date of Birth: Age: Social
MEDICAL FORM (Please Fill in all Information)
MEDICAL FORM (Please Fill in all Information) Last Name First M.I. Spouse/Parent Name Home Phone Business or Cell Phone Home Address City and State Date of Birth Zip Code Sex M F Social Security # E-Mail
We look forward to serving you and your ophthalmic needs. Please do not hesitate to contact our office if we can be of any further assistance.
Welcome to Biltmore Eye Physicians! Enclosed in our new patient packet are the following items: 1. Patient Registration 2. Credit Policy and Financial Agreement 3. Notice of Privacy Practices 4. Medical
Metrolina Dermatology and Skin Surgery Specialists Park Road, Suite 100 Charlotte, NC
Metrolina Dermatology and Skin Surgery Specialists 10502 Park Road, Suite 100 Charlotte, NC 28210 www.metrolinadermatology.com Dear Patient, We thank you for choosing Metrolina Dermatology and Skin Surgery
INSURANCE INFORMATION (Please present insurance cards at the time of check in)
421 N. RODEO DR., SUITE T-7, BEVERLY HILLS, CA 90210 T: (310)274-5372 F: (310)274-5380 Date: / / PATIENT REGISTRATION FORM Name: Jr. Sr. Last First Middle Prefer to be called: Title: Mr. Mrs. Ms. Miss
I Federal Law requires us to ask race: Hispanic Non-Hispanic
Today's Date < McCoy VISION Please Contact Me at this Number Patient Registration Chart# - Patient's Name (last, first, middle initial) Date of Birth Sex Home Phone Street Address City State Zip Work
This form should be filled out completely
This form should be filled out completely Patient Name First Name Middle initial Last Name (Circle One) Male Female Date of Birth Address / Street Address City State Zip Code Phone # s Home _ Work _ Cell
Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
9201 Sunset Boulevard Suite 709 West Hollywood, CA 90069 New Patient 310. 275. 5533 Fax 310. 275. 5523 info@benjamineye.com www.benjamineye.com Patient Information Title Dr. Mr. Mrs. Ms. Sex M F Patient
Welcome to West County Vision Center
Welcome to West County Vision Center Thank you for choosing our office for you eye care needs! Please take a moment to complete the following information. If you have any questions, please do not hesitate
REGISTRATION/CONSENT FORM
Today s Date: REGISTRATION/CONSENT FORM (PLEASE PRINT) PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Is this your legal name? If not, what is your legal name? (Former name):
Burnet Eye Care & Llano Eye Care P.O. Box 426 Burnet, TX phone 102 E Young St Llano, TX phone
Burnet Eye Care & Llano Eye Care P.O. Box 426 Burnet, TX 78611 512-756-2131 phone 102 E Young St Llano, TX 78643 325-247-2020 phone PATIENT REGISTRATION Patient s Name Today's Date Mailing Address City
(Last) (First) (Middle) Home Phone: Work: Cell: (Include Extension, if applicable) (OK to Text )
JEFFREY S. GREENWALD, M.D. MICHAEL S. HENNER, M.D. ROBERT W. DEMETRIUS, M.D. KEMKA S. OGBURIA, M.D. DINAH M. WARNER, M.D. KATHLEEN B. ZENDELL, M.D. STEVEN M. PRICE, M.D. EDWARD J. POSNAK, M.D. ASHLEY R.
Stark County Surgeons, Inc Patient Information. Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - -
Today s Date: / / Patient Information Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - - Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Other phone: ( ) - E-Mail
Illinois Dermatology Institute
Illinois Dermatology Institute PATIENT INFORMATION (Please Print) Today s _/ / Name: Last First M.I. Mailing Address: Street City State Zip Code Home Phone ( ) Work Phone ( ) Cell Phone ( ) OK to leave
PATIENT REGISTRATION. Patient s Name: (Last) (First) Home Address: City State Zip. Home Phone: Cell Phone: Work Phone:
PATIENT REGISTRATION Date: Patient s Name: (Last) (First) Home Address: City State Zip Home Phone: Cell Phone: Work Phone: Email Address: May we call you at work? Yes No Date of Birth: Sex: M / F / Other
If you circled married, please complete Spouse s Information below: Spouse s Last Name: First Name:
METROPOLITAN EYE CARE Scott B. Pomerantz, M.D. Thomas J. LoPresti, O.D Lori R. Kaplan, O.D. 523 Forest Avenue Paramus, NJ 07652 Tel. (201) 262-5070 Fax (201) 262-5333 Please Complete and Sign Where Indicated
Patient Name M/F D.O.B. / /
Patient Name M/F D.O.B. / / Phone ( ) Cell ( ) STATUS: Single Married Divorced Widow Soc. Sec. # - - Insurance Name Group Policy # Guarantor Subscriber Occupation /Student Work Place Email @. (Please provide
History and Intake Form. Date of Birth:
History and Intake Form Name: Date of Birth: Name I prefer to be called: Past Medical History: (please check all that apply) Anxiety Arthritis Asthma Atrial fibrillation (irregular heartbeat) BPH Bone