2535 Capital Medical Boulevard Tallahassee, FL (850) palmereye.com

Transcription

1 2535 Capital Medical Boulevard Tallahassee, FL (850) palmereye.com DEAR CATARACT PATIENT: Thank you for choosing our practice! We strive to provide the best quality of care and customized vision solutions for our patients through premium vision technology. We hope this informational packet gives YOU the most up to date education on cataracts and lens options available today. Please take the opportunity to be fully informed before coming in for your appointment. Cataracts are a normal part of the aging process. Cataracts are typically linked to birthdays the more birthdays you have, the more likely you are to develop a cataract. Being diagnosed with a cataract may seem frightening. However, cataract surgery is considered to be one of the safest and most successful surgeries in the United States. Once you understand what a cataract is, how it is removed, and the life-changing benefits cataract surgery can bring, you'll likely wish you'd had the procedure sooner. Here at Palmer Eye Center, there are numerous lens options to customize your vision after cataract surgery: 1. ReSTOR 2. Toric 3. Crystalens 4. Tecnis Acrysof Toric, Acrysof ReSTOR, Crystalens, & Tecnis 5. Basic Monofocal The Toric, ReSTOR, Crystalens, & Tecnis provide premium vision technology. The Toric is specifically designed to address those who have a significant amount of astigmatism. In years past, cataract surgery removed the cataract, but a patient with high astigmatism still required glasses for near and distance vision. The design of the Toric makes it possible to reduce or eliminate corneal astigmatism and significantly improve uncorrected distance vision, independent of eyeglasses and contact lenses. The ReSTOR, Tecnis, and Crystalens are designed to provide a full range of vision-near, far and everything in between. Based on FDA clinical data from Alcon Laboratory, there is an 80% chance you will never have to wear glasses again. The goal of the premium multi-focal intraocular lenses is to allow you to read the newspaper, prescription bottles, mail, and to see many other things near and far without glasses. Basic Monofocal With single-vision lens implants, there is a high likelihood you will need glasses for most near-vision activities after your surgery, and if you have an astigmatism for most distance-vision activities too. Medicare and most private insurance carriers will pay the majority of your cataract surgery and the monofocal lens. This is considered basic coverage. Here at Palmer Eye Center, financial considerations should not be an obstacle in obtaining Vision Correction. Our goal is to make our procedures affordable for any budget. It is for this reason that we make things affordable, by offering a combination of expertise, experience and advanced technology at a price everyone can afford. You may choose any of the following payments: 1. Cash or Check 2. Credit Card 3. Monthly Payment Plan, which includes: a. Zero Down Payment & Zero Interest for 12 Months b. Zero Down Payment & Low Monthly Payment w/ Interest c. Zero Prepayment Penalty We greatly appreciate your choosing us to serve you for your vision needs as we strive for perfection in visual outcomes.

2 CONSENT FOR DILATING EYE DROPS INFORMATION REGARDING DILATING EYE DROPS Dilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye. Dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome. While dilated you may experience glare, difficulty focusing and contrast. It is not possible for your ophthalmologist to predict how much your vision will be affected. However, we advise not to operate any motorized vehicle or machinery as well as getting assistance with electric wheelchairs due to the risk of falling and/or injury. Because operating any motorized vehicle may be difficult after an examination, it s best if you make arrangements not to drive yourself. Adverse reactions occur rarely, however dilating drops can provoke acute angle-closure glaucoma, allergic reactions, increased blood pressure, irregular heart rates, dizziness, and increased sweating. This is extremely rare and treatable with immediate medical attention. If your child is dilated and you notice any agitation or unusual response contact us or the emergency room immediately. Additionally we recommend sun glasses which we can provide to you I hereby authorize Dr. Palmer, Dr. Torrans and/or such assistants as may be designated by him/her to administer dilating eye drops. I understand the eye drops are necessary to diagnose my condition. CONSENT FOR REFRACTION INFORMATION REGARDING REFRACTION Refraction is an essential part of a complete eye exam. It is the process of determining the eye s refractive error, or the need for corrective glasses and/or lenses. Refraction is sometimes necessary depending on the patient s diagnosis and/or visual complaints presented that day. For example, if a patient is experiencing blurred vision or a decrease in visual acuity on the eye chart, refraction is necessary to determine if this is due to a need for corrective lenses or due to a medical problem. A refraction will be done when it is necessary, to determine the cause for a decrease in your vision or simply to provide you with a means to achieve your best corrected vision. Our mission is to ensure you have the very best possible vision. For this reason you have come to us for an eye exam. At the start of your eye exam, our technician will measure your visual acuity on the eye chart and review the quality and status of your glasses. If your vision is not 20/20, the technician will begin the process of refraction. After your exam, you will receive your new prescription which you can use should you break, lose, scratch, or wish to purchase new glasses afterward. For patients anticipating cataract surgery, refraction is also required by insurance companies to provide documentation for the medical necessity for eye surgery. We must demonstrate that your vision cannot be simply improved with a glasses prescription. However most insurance plans, including Medicare, DO NOT cover the refraction. This is true even after you have had eye surgery. Federal law requires that we bill for refractions. We can no longer offer this service for free and must charge you when it is performed. Our charge for refraction is $ If this fee is made paid to Palmer Eye Center at check-out on the day of office visit, we will accept $35.00 for your refraction to defray billing costs. Although refractions are typically a non-covered benefit, all refractions are billed to your private insurance company and a refund issued to your account, should you insurer cover the charge. Patient (or person authorized to sign for patient) Date Witness Date

3 Mr. Mrs. Ms. Dr. Single Married Divorced Widowed NAME: SOCIAL SECURITY#: DOB: STREET ADDRESS: CITY: STATE: ZIP: HOME PHONE: CELL: WORK PHONE: *please provide 2 contact numbers if possible. EMERGENCY CONTACT: CELL: WORK PHONE: Employer s Name: Occupation: Employer s Address: City: State: Zip: Spouse s Name: Spouses Employer: Responsible Party Information: If the patient is a child, Name of Guarantor: Street Address (if different from above): City: State: Zip: How were you referred to our office: please circle and add name if applicable. Previously seen in our office Yellow Pages Insurance Plan Website Google Doctor -Name: REASON FOR VISIT: please circle Friend/Family- Name: Cataract Evaluation Lasik Evaluation Diabetic Eye Exam Glaucoma Exam Referred by Physician Dry Eye Exam Routine - No Particular Problems Possible Medical or Surgical Problem Other, please explain: PAST EYE HISTORY: please circle Eye Injury Infections Double Vision Muscle Imbalance Glaucoma Diabetic Eye Disease Cataracts Retinal Problem Halos Blurry Vision Other, please explain: FAMILY HISTORY: please circle Blindness Glaucoma Arthritis Cancer Diabetes Thyroid disease Heart disease High blood pressure Kidney disease Lupus Stroke Other, please explain: CIRCLE IF YOU HAVE THE FOLLOWING PROBLEMS: Blurr/Fuzzy Vision Tearing or Discharge Burning Itching Redness Floaters/Cobwebs Flashing lights Dry Eye Problems with Glasses Other, please explain:

4 What medicines are you currently taking (include dosage and frequency): Skip if you will attach a list. Pharmacy Preference: Location: Phone #: What are your allergies? Please specify: In the past 5 years, list any surgeries or injuries with date of occurrence: YOUR MEDICAL HISTORY: please circle HIV or AIDS Tuberculosis Drug Dependence Alcohol Dependence High Blood Pressure Diabetes Thyroid trouble Cancer Sinus Infection Headaches Skin Disorder Hay Fever Lupus Arthritis Blood transfusion Smoker Other, please specify: ARE YOU NOW: please circle Pregnant Possible Pregnant Not Pregnant Unknown Using Contraceptives Do you wear Contacts : Yes No What Brand/Power/B.C./Diameter? Which Cleaning Solution? Do you wear glasses: Yes No If yes, how long have you had the current prescription? Patient Acknowledgment of Having Received & Read or Been Read the Notice of Health Information Practices (HIPAA) I have been provided the opportunity to read, or it has been read to me, the Notice of Health Information Practices Palmer Eye Center. I understand that Palmer Eye Center is committed to treating and using protected health information about me responsibly. I understand my rights as it relates to my records at Palmer Eye Center and understand how information about me may be used and disclosed. I understand that my health record is the physical and legal property of Palmer Eye Center but the information belongs to me. I may have access to inspect, amend or obtain a copy of my health information. Costs will incur for copies of my records, and appointments must be made with the Privacy Officer to inspect, access or amend my health information. I understand that Palmer Eye Center is required to maintain the privacy of my health information. Palmer Eye Center will require my authorization to release my health information to outside sources with the exception of disclosures for purposes of Treatment, Payment and Healthcare Operations. These may include: access to my health information by Palmer Eye Center staff and physicians; billing to myself or a third-party payer; in addition, business associates of Palmer Eye Center may from time to time, have access to my health information, but, I am assured that proper Business Associates Agreements are in place, insuring the protection of my health information; upon the physicians best judgment, we may disclose to a family member, relative or close personal friend or any other persons you identify, health information relevant to that person s involvement in my care; may be used for research data; funeral directors; organ procurement; marketing; FDA; public health or legal authorities; and/ or law enforcement purposes. Palmer Eye Center may call me with appointment reminders, cancellations and may leave voice mail messages at my home or place of employment. Palmer Eye Center may contact me via . I have read and understand the Health Information Practices of Palmer Eye Center. Patient Name: Date: Signature: Witness: List the names we can fully discuss your medical condition with: Name: Name: Relationship: Relationship:

5 PALMER EYE CENTER FINANCIAL POLICY We are dedicated to providing our patients with the highest quality ophthalmic care and to running our clinic efficiently. Please assist us in achieving these goals by complying with our financial policy. Payment is due at the time the service is provided. It is your responsibility to verify insurance and determine the status of coverage (co-pay and deductible) prior to your visit. REQUIREMENTS FORMS OF PAYMENT CO-PAYS & DEDUCTIBLES MEDICARE MEDICAID WORKERS COMP PRIVATE INS & MANAGED CARE SELF-PAY Photo identification with current address, current original insurance card (including Medicare, Medicaid, BCBS, etc.) Cash, check, major credit card, or Chase Credit Plan All Medicare, Medicaid, and other insurance plan co-pays and deductibles are payable upon Check-in. It is your responsibility to know your portion payable at the time of service. We accept assignment and will file all Medicare claims. At the time of service you are responsible for 20% of the Medicare allowable fee, plus the deductible and any service charge not covered by Medicare (such as a refraction). A current copy of the Medicaid card is required prior to treatment or the patient will be rescheduled. Workers Compensation authorization is required prior to the appointment. Otherwise, we cannot treat the patient. If you participate in a plan that we accept we will be happy to file your insurance claims for you. Otherwise payment in full is your responsibility. Please note that you are ultimately responsible for payment if you private insurance (excluding Medicare and Medicaid primary) company denies payment. Payment is expected at Check-In prior to being seen by the doctor. You may call our office for an estimate of our fees. Any refund or balance due will be calculated at the Check-Out. If you are not prepared to cover your exam, then we can offer you coverage through a Chase Credit Plan or reschedule your appointment. DRIVERS FORM We will be happy to complete a Driver s Form for you for a charge of $10.00 per form and they will be ready in 2-3 business days. OTHER FORMS OTHER INFORMATION REFUNDS For any additional insurance forms or dictated letters from our doctors, the fee is $25.00 per form and they will be ready in 2-3 business days. A request for medical records is a $1.00 per page & $2.00 per page for color. Any check returned to our office for non-payment will generate an additional processing fee of $ We can assist you with setting up a payment plan through Chase Credit in order to pay an outstanding balance. Accounts turned over to a collection agency will also incur a $50.00 administrative fee as well as any additional fees associated with that effort, including court costs. Credit balanced under $50.00 will remain as a credit on your account to be applied to your next visit unless a refund is requested. I have read and accept the terms of Palmer Eye Center, LLC. financial policy. I agree to pay for services rendered by Palmer Eye Center, LLC. that are not covered or paid by my insurance company, including Medicare and Medicaid. Name (print): Date: Signature:

6 PALMER EYE CENTER PAYMENT AUTHORIZATION POLICY Patients with full insurance coverage I certify that I have full coverage (i.e. - Medicare & supplemental insurance) for today s office visit. I agree to pay for any charges that may be considered non-covered such as a refraction. Signature of Patient Patients with insurance co-pay or deductibles I understand that payment is due on the date services are rendered. I agree to take full responsibility for any co pay or charges that are applied to my deductible. I wish to pay my co pay and/or deductible now by cash, check or credit card. I further understand that any unpaid charges will be charged to my credit card on file after first being billed to my insurance carrier. Signature of Patient Patients without insurance coverage I certify that I have no insurance coverage and understand that payment is due on the date services are rendered. I agree to take full responsibility for today s charges. I am either paying by cash or authorize PEC to charge my credit card for today s visit. Signature of Patient CANCELLATION POLICY It is our priority to provide quality eye care to you and all of our patients, for us to do this it s essential for patients to keep appointments or give us sufficient notice if you are unable to do so. Patients will be reminded by phone a day prior to their examination, which will give you the opportunity to reschedule to another date if unable to make current appointment. Signature of Patient CARD ON FILE Being the cardholder I understand and agree to the terms set forth in this agreement, agree to pay, and specifically authorize PEC to charge my credit card for the services provided. PEC will provide me upon request with an itemized statement detailing all of my charges. I further agree that in the event my credit card becomes invalid, I will provide PEC with a new valid credit card upon request, to be charged for the payment of any outstanding balances owed to PEC. Name (print): Date: Signature:

7 PALMER EYE CENTER PRE-SURGICAL CATARACT PATIENT QUESTIONNAIRE Patient Name: Date: Visual Functioning: Do you have difficulty, even with glasses, with the following activities? 1. Reading small print, such as labels on medicine bottles, telephone books, or food labels? Yes No 2. Reading a newspaper or book? Yes No 3. Reading a large-print book, or large-print newspaper, or large numbers on a telephone? Yes No 4. Recognizing people when they are close to you? Yes No 5. Seeing steps, stairs, or curbs? Yes No 6. Reading traffic signs, street signs, or store signs? Yes No 7. Doing fine handwork like sewing, knitting, crocheting, or carpentry? Yes No 8. Writing checks or filling out forms? Yes No 9. Playing games such as bingo, dominoes, or card games? Yes No 10. Taking part in sports like bowling, handball, tennis, or golf? Yes No 11. Cooking? Yes No 12. Watching television? Yes No Symptoms: Have you been bothered by: 1. Poor night vision? Yes No 2. Seeing rings or halos around lights? Yes No 3. Glare caused by headlights or bright sunlight? Yes No 4. Hazy and/or blurry vision? Yes No 5. Seeing well in poor or dim light? Yes No 6. Poor color vision? Yes No 7. Double vision? Yes No

8 Driving 1. Have you ever driven a car? Yes (continue) No (stop) 2. Do you currently drive a care? Yes (continue) No (stop) 3. How much difficulty do you have driving during the day because of your vision? No difficulty. A little difficulty. A moderate amount of difficulty. A great deal of difficulty. 4. How much difficulty do you have driving at night because of your vision? No difficulty. A little difficulty. A moderate amount of difficulty. A great deal of difficulty. 5. When did you stop driving? Less than 6 months ago. 6 to 12 months ago. More than 1 year ago. Cataract surgery can almost always be safely postponed until you feel you need better vision. If stronger glasses will not improve your vision anymore, and if the only way to help you see better is cataract surgery, do you feel your vision problem is bad enough to consider cataract surgery now? Yes No Patient Signature: Date: Notes/Med List