505 Health Blvd
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- Donald Preston
- 5 years ago
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1 505 Health Blvd Daytona Beach, Fl Welcome to DiGaetano Cataract Services. We are delighted to have you as new patient. Our doctors specialize in the medical and surgical care of eyes. We are the longest established practice in the greater Daytona Beach area, preserving a tradition of providing the finest patient care available. The enclosed forms should be filled out as completely as possible, especially your list of medications. The appointment time below has been reserved for you. Please remember to bring with you these forms, insurance cards, identification cards and your eyeglasses to your appointment on:. We reserve the right to discharge a patient from our care if a patient no-shows or cancels without an advanced notice of 24 hours, on 3 or more occasions. Dr. DiGaetano performs her surgeries at Atlantic Surgery Center. In the event you need a surgical procedure, please be aware that the surgical facility may not be an in-network facility. Please be sure to check with your insurance carrier to confirm and to also verify that you have out of network benefits. Your out of network benefits may cover the facility. If you have any questions, please contact your insurance company or the insurance department at the surgical facility. Atlantic Surgery Center 541 Health Blvd. Daytona Beach, Fl Thank you for choosing our office for your eye care needs. We look forward to meeting you!! Margaret DiGaetano, M.D. Jennifer Iannarelli, OD Robert Young, M.D. Itza Acevedo, M.D. DiGaetano Cataract Services, PA
2 MRN Name: Nick Name: Date: / / Address: City: State: Zip: Gender: Female Male Other DOB: / / SS#: Race: Ethnicity: Hispanic Non-Hispanic Other: Decline Preferred Language: (Specify) Marital Status: Single / Married / Divorced / Other Home Phone: Cell Phone: Are you Employed? Yes No How did you hear about our office: Do we have your permission to leave a voic regarding test results? Yes No Do we have permission to advise family members of your medical status? Yes No Contact: Relationship: Phone: Primary Care Physician: Phone: Do you have an advanced healthcare directive or designated decision maker on file with a healthcare provider? No Yes, which provider? ACTIVE CONDITIONS: Are you CURRENTLY receiving treatment for any condition(s) listed below? Check Y or N End Stage Renal Disease GERD PAST SURGICAL HISTORY: Have you ever had any of the following surgeries? Check Y or N Y N Y N Appendix Removal (Appendectomy) Kidney Stone Removal Bladder Removal (Cystectomy) Kidney (Nephrectomy) Mastectomy (Left, Right, Bilateral) Joint Replacement, Knee (Right, Left, Bilateral) Lumpectomy (Left, Right, Bilateral) Joint Replacement, Hip (Right, Left, Bilateral) Breast Biopsy (Left, Right, Bilateral) Spleen Removal (Splenectomy) Breast Reduction Prostate (Prostatectomy) Breast Implants TURP (transurethral resection of the prostate) Gallbladder Removal (Cholecystectomy) Skin Biopsy Coronary Artery Bypass Hysterectomy (PTCA) Percutaneous transluminal coronary angioplasty Heart Valve Replacement Transplant History (check all that apply) Other surgeries not listed? Heart Liver Kidney Pancreas Y N Hearing Loss AIDS/HIV Hepatitis: Please indicate type: Appt. reminders and service surveys Anxiety Hypertension Arthritis High Cholesterol Asthma Hyperthyroidism Atrial Fibrillation Hypothyroidism Bone Marrow Transplantation Leukemia BPH (Benign Prostatic Hyperplasia) Lung Cancer (currently receiving treatment) Breast Cancer (currently receiving treatment) Lymphoma Colon Cancer (currently receiving treatment) Prostate Cancer (currently receiving treatment) COPD Radiation Treatment Coronary Artery Disease Seizures Depression Stroke Diabetes Other medical conditions not listed?
3 FAMILY HISTORY: Is there any family history of the following? Check Y or N. In the corresponding area indicate (Mother, Father, Sister, Brother, Grandparent) Y N Cancer Diabetes High Blood Pressure Thyroid Glaucoma Macular Degeneration Retinal Detachment Strabismus (Lazy Eye) OCULAR HISTORY: Have you ever had any of the following conditions? Check Y or N Y N Allergic Conjunctivitis Pseudo Exfoliation Blepharitis Diabetic Retinopathy (Left, Right) Cataract (Left, Right) Strabismus (crossed eye or wall eye) Cornea dystrophy (Left, Right) Macular Degeneration (Left, Right) Glaucoma (Left, Right) Retinal Tear (Left, Right) Macular pucker or wrinkle (Left, Right) Vitreous Floaters (Left, Right) Dry Eyes PVD (Left, Right) Ophthalmic Migraine Ocular Hypertension (Left, Right) Narrow Angles (Left, Right) OCULAR SURGICAL HISTORY: Have you ever had any of the following surgeries? Check Y or N Y N Blepharoplasty (Left, Right) Cataract Surgery (Left, Right) Corneal Transplant (Left, Right) Eye Muscle Surgery (Left, Right) DSAEK: Cornea (Left, Right) Intravitreal Injections (Left, Right) LASIK, PRK, RK or other refractive surgery (Left, Right) Peripheral iridotomy Laser (Left, Right) Glaucoma Laser (Left, Right) Ptosis i.e. droopy eyelid Repair (Left, Right) Punctal Plugs (Left, Right) Retinal Laser (Left, Right) Trabeculectomy or glaucoma surgery (Left, Right) YAG laser Capsulotomy (Left, Right) Social History: Y N Do you smoke Cigarettes? If no, when did you quit? / Did you have a Pneumonia Vaccination? If yes, when? / Did you receive an Influenza (aka flu ) shot? If yes, when? / Are you allergic to Latex? Do you feel safe at home? How many times in the past year have you had 4 or more alcoholic drinks in a day? Never None 1-2 Days 3 or more days
4 PLEASE LIST ANY MEDICATION ALLERGIES PLEASE LIST ALL MEDICATIONS Medication Name Dose/Strength How Often Example: Aspirin 81mg 1/day Preferred Pharmacy: Phone: Address/ City/Zip: Primary Insurance Carrier: Name of Insured (Subscriber): Subscriber DOB: / / Subscriber Gender: Male Female Relationship to patient: PAYMENT OF BENEFITS/ AUTHORIZATION OF TREATMENT I hereby authorize treatment from any licensed medical professional within DiGaetano Cataract Services, PA. I understand that this authorization may be used now or in the future. PAYMENT IS EXPECTED AT THE TIME OF SERVICE FOR "YOUR PART" OF THE CHARGES. We accept VISA, MasterCard, AMEX and DISCOVER for your convenience. Your signature below indicates that you understand and accept this policy. I request the direct payment of all authorized medical benefits to be made to DiGaetano Cataract Services, PA for any services I received by the physicians of DiGaetano Cataract Services, PA. I authorize any holder of medical information about me to release this information to process my claims or meet legal requirements. I permit a copy of this authorization to be used in place of the original. This assignment will remain in effect until revoked, in writing. I understand that because these services were performed for me or my legal dependent, I am financially responsible for all charges incurred. DiGaetano Cataract Services, PA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Signature: Date: / / OFFICE POLICIES Please read carefully, if you have any questions regarding our office policies do not hesitate to ask!! DRIVING POLICY Dilating drops enlarge the pupils of the eye to allow for the examination of the inside of your eye. These drops usually cause blurred vision. After an examination with dilating drops, you should not drive yourself. Instead, you should make alternative arrangements for transportation after your examination. If you do choose to drive yourself, you acknowledge that you understand the risks and accept full responsibility for any injuries to yourself or others. Adverse reaction, such as acute angle-closure glaucoma may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical treatment. You hereby authorize the doctors of DiGaetano Cataract Services and/or their assistants to administer dilating eye drops during your treatment. I have read and understood the above paragraphs Patient Initials
5 INSURANCE POLICY Your insurance policy is a contract between you and your insurance company. We accept Medicare assignment and will file claims with certain medical plans. Claims will be filed based on the information you give us. To file an insurance claim for you, we must make a copy of your insurance card. In the event a claim is denied, or should payment not be received within 45 days of claim submission, we will refile the claim one time. Please call your insurance company if you are not certain we participate with your plan. As a subscriber of your insurance, it is your responsibility to be aware of the limitations and conditions of your policy. Patients are responsible for any co-pays and/or deductibles. Payment is due at the time of service unless prior arrangements are made. I have read and understood the above paragraph Patient Initials APPOINTMENT POLICY We have reserved an appointment time for you. If you are not able to make your appointment, please contact the office at your earliest convenience. This will allow us to schedule another patient, in need of our care, to see one of our qualified eye Doctors on an earlier date. If you have a scheduled appointment and you do not show to that appointment or contact our office 24 hours in advance, you will be charged a fee of $ Our office reserves the right to discharge a patient from our care, when 3 or more appointments have been missed with no communication or cancellations without prior notification. I have read and understood the above paragraphs Patient Initials REFRACTION POLICY A refraction is a test / procedure ordered by the physician to assist them in determining what your best vision is with lenses and if your vision can be improved with corrective lenses. If your vision cannot be corrected with a prescription for corrective lenses, it may indicate a problem with the health of your eyes. It can also be used to detect certain types of vision loss. We want to make you, the patient, aware of the $40.00 fee for this test to be completed. We will file a claim to your insurance carrier on your behalf, but Medicare and some other insurance plans state this is a non-covered service. Therefore, this fee would be the patient s responsibility. WHY IS THE REFRACTION CHARGED AND NOT COVERED? Medicare and certain insurance companies do not consider a refraction a medical service. They (Medicare) acknowledges that this test / procedure is separate to the rest of the eye exam and therefore there is a separate fee. I have read and understood the above paragraph Patient Initials I acknowledge that the facts provided on this registration are true and correct. I also understand it is my responsibility to notify the office of any personal or insurance changes. I understand the privacy practices are posted and a copy is available at my request. I hereby authorize release of any medical information necessary to process my insurance claim and also ASSIGN to the DOCTOR all payments from insurance including Medicare. I authorize DiGaetano Cataract Services to correspond via address given above. Patient Signature: Date: (or Guardian s signature if patient is a minor) THANK YOU FOR ALLOWING US THE OPPORTUNITY TO CARE FOR YOUR EYES!
Patient (Optional).
ALAN R. MALOUF, MD, PA 17000 Science Drive, Suite 108 PATIENT REGISTRATION PLEASE PRINT First Name Ml Last Name Address City. State Zip Code Home# Work# Cell # Male/Female Date of Birth Marital Status
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PATIENT INFORMATION FORM
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Continued on Reverse Side
PATIENT REGISTRATION FORM Date Male Female First Middle Last Email Address Mailing Address City State Zip Code Home Phone Work Phone Cell Phone Social Security Date of Birth Ethnicity: Hispanic or Latino
Patient Update Information
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Name of person responsible for this account: Relationship: Address: City: State: Zip: PLEASE PRESENT COPY OF YOUR INSURANCE CARDS
PATIENT INFORMATION Patient Legal Name: Preferred Name: Date of Birth: Age: Male Female Social Security #: Married Single Widow Divorced Address: City: State: Zip: Home Phone: ( ) Work Phone: ( ) Cell
Name: Mr Ms Mrs Dr Last First Initial. Mailing Address: City: State: Zip Code:
Name: Mr Ms Mrs Dr Last First Initial Mailing Address: City: State: Zip Code: Home #: Work #: Cell #: #Preferred: Email: Date of Birth: Age: Sex: F / M Marital Status: M / S / D / W SSN : Employer: Student:
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HIPAA Patient Consent Form
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PATI ENT INFORMATION Date=----~--- First Name: Ml: Last Name: ------------ Date of Birth: Sex: [ ] Male [ ] Female Address: City,State, Zip: Home Phone: Cell Phone:, Work Phone: Email Address: Marital
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If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
Medicare Patient Registration
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If you have any questions about this payment method, do not hesitate to ask. Visa MasterCard American Express Discover Other:
To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
HIPAA Patient Consent Form
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Patient Registration Form
Patient Registration Form Name: Jr Sr Dr First Middle Last SS#: - - DOB: / / Sex: M F Primary Language: Race: Hispanic Non-Hispanic Decline E-Mail address: Is it okay to email you about upcoming cosmetic
Reason for visit today: How did you hear about us?
**Please be sure to fill out EVERY section thoroughly. Indicate N/A for sections that do not apply to you Name: Street Address: Date: City / State: Zip Code: Date of Birth: Gender: Marital Status: Occupation/Employer:
Are you interested in receiving information about special promotions? Yes! No thanks.
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Street Address: Apt. # City State Zip. Employer Name and Address. City State Zip. Name of Spouse or Guardian. Emergency Contact Name and Phone
Patient Name Social Security Number: Date of Birth: Age: Street Address: Apt. # City State Zip Home Phone: ( ) -- Mobile Phone: ( ) -- Employer Name and Address City State Zip Business Phone ( ) -- Occupation
Privacy Practices. Patient Name (please print) Patient Date of Birth. Signature of Patient/Guardian
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PATIENT INTAKE FORM. UNDER 18 years old?: INSURANCE INFORMATION (Please give your insurance card to the receptionist.)
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Would you like to receive our monthly ed newsletter? Yes! No thanks.
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Medical History Form
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Please Complete All Sections on All Pages. RELEASE OF MEDICAL INFORMATION to other individuals if we are unable to reach you (HIPAA requirements)
Please Complete All Sections on All Pages PREFERRED PHONE # ALTERNATE PHONE #_ EMAIL ADDRESS BIRTH DATE PATIENT S NAME: (Last, First, MI) SEX: PRIMARY ADDRESS (STREET) APT# CITY STATE ZIP -- ALTERNATE
On the Day Of Your Appointment You Will Need To Bring The Following:
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PATIENT REGISTRATION
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PATIENT REGISTRATION
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INSURANCE INFORMATION: This information is REQUIRED
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PATIENT INFORMATION. Race: Ethnicity:
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PATIENT INFORMATION: DATE: REFERRAL INFORMATION: INSURANCE INFORMATION: EMERGENCY CONTACT: PHARMACY INFORMATION:
PATIENT INFORMATION: DATE: Patient Name: Gender: DOB: Address: Preferred Phone Other Phone SSN: Occupation: Employer: Address: Phone#: REFERRAL INFORMATION: Who referred you to our practice? Who is your
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MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED GENDER: MALE FEMALE
- PATIENT INFORMATION: (PLEASE PRINT) WHO SHOULD WE THANK FOR REFERRING YOU TO OUR OFFICE? PATIENT FULL NAME: CURRENT AGE MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED GENDER: MALE FEMALE ADDRESS: CITY:
Natural Image Skin Center Registration Form
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I Federal Law requires us to ask race: Hispanic Non-Hispanic
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New Patient Registration
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NEW PATIENT FORM (please print)
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Personal Information Patient Registration Form Today s Date: Patients First Name: Date of Birth: / / Social Security #: - - Patients Last Name: Sex: Male / Female Marital Status: Married Single Divorced
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PATIENT REGISTRATION FORM Date Patient Name: DOB: Sex: M F Address: City/State/Zip: Email: Social Security #: Please provide contact information and indicate your preferred contact number: Home Phone:
New Patient Information
New Patient Information PATIENT INFORMATION: Last Name: First Name: MI: Preferred Name (If different than above): DOB: Sex: M F Address: Apartment # City: State: Zip Code: Home Phone: Cell: Work: What
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
NEW PATIENT INFORMATION FORM Michael Metzger MD Charles Harring MD Andres Ruiz MD Gustavo Cardenas MD Heidi Templin ARNP
NEW PATIENT INFORMATION FORM Michael Metzger MD Charles Harring MD Andres Ruiz MD Gustavo Cardenas MD Heidi Templin ARNP Patient name: Today's Date: / / First Last Referred by: Primary care physician:
Please Present Insurance Card at Each Office Visit
PATIENT REGISTRATION FORM RONALD J ESCUDERO, MD, FACS Please print clearly and fill out completely Patient Legal Name Birthdate Age Address Social Security # City ST ZIP Email Phone Numbers ( ) Home (
Mailing Address: Name: FIRST MIDDLE LAST. Mailing address: If different from patient. Telephone Numbers: Home Day Number
Dermatology Center South PC 2800 Ross Clark Circle, Suite 2 DOTHAN, ALABAMA 36301 REGISTRATION FORM FOR DEPENDENTS] Patietnt Name: First Middle Initial Last of Birth: / / Sex: Male Female Month Day Year
Illinois Dermatology Institute Patient Information (Please Print) Today s Date / /
Illinois Dermatology Institute Patient Information (Please Print) Today s Date // Name: Last First MI Mailing Address: Street City State Zip code Home Phone( ) Alternate Phone( ) Email Ok to leave message:
Patient Name: Todays Date: Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status
Patient Name: Todays Date: *General Patient Information Patient Name Age Date of Birth / / SS# - - Sex: M F Marital Status Email Phone: Home ( ) - Cell ( ) - Mailing- Address, City, State & Zip *PARENT
Primary Insurance. Secondary Insurance. Emergency Contact
Street Address: Gender: City, State, Zip: Home Phone #: Marital Status: S M D W *Cell Phone #: *Do you authorize Southeastern Retina Specialists to send you appointment notifications via text messaging?
PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
Dr. Peter F. Gregory, D.P.M. Patient s Name: Date: / / Address: City State Zip Date of Birth: / / Sex: Male Female Home Phone: Cell Phone: Business Phone: Email: (Please check preferred method of contact
ADDRESS: CITY: STATE:
PATIENT INFORMATION FORMS (JUNE 2016) PATIENT INFORMATION: (PLEASE PRINT) WHO SHOULD WE THANK FOR REFERRING YOU TO OUR OFFICE? PATIENT FULL NAME: MARITAL STATUS: GENDER: SINGLE DIVORCED MALE MARRIED WIDOWED
Minor Patient Information
Minor Patient Information MINOR S INFORMATION: (TO BE FILLED OUT BY CUSTODIAL PARENT OR LEGAL GUARDIAN) Last Name: First Name: MI: Goes By (If Different Than Above): DOB: Sex: M F Ethnicity/Race: Preferred
Retina Consultants of Oklahoma, PLLC Patient Information Sheet Date:
Retina Consultants of Oklahoma, PLLC Patient Information Sheet Date: First Name: MI: Last Name: Address: City: State: Zip: Phone: ( ) Wk. Phone: ( ) Cell: ( ) Date of Birth: Age: Height: Weight: Sex: q
THE WOODLANDS FAMILY MEDICINE GHPMA
THE WOODLANDS FAMILY MEDICINE GHPMA PATIENT INFORMATION NAME: SEX: [M] [F] ADDRESS: CITY: STATE: DATE OF BIRTH: ZIP: SS#: HOME PHONE: CELL PHONE: WORK PHONE: MARITAL STATUS: [ ] MARRIED [ ] SINGLE EMAIL
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
We look forward to meeting you, and will be available for you at any time. Dr. Douglas Scott, M.D. Dr. Kirk Johnson, M.D.
Welcome to Orthopedic Associates of the Lowcountry. Thank you for your confidence in allowing us to help care for your health. It is a responsibility we respect, and take very seriously. Please take the
Medicine and Surgery of the Foot PATIENT INFORMATION PERSON RESPONSIBLE FOR PAYING THE BILL FAMILY PHYSICIAN INFORMATION HEALTH INSURANCE INFORMATION
PATIENT REGISTRATION Thank you for choosing our office! Please complete all pages. Patient Name: PATIENT INFORMATION Home Address: City: State: Zip: Sex: S S#: Marital Status: S,M,O or minor E-mail: Home
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014
EAR, NOSE, AND THROAT ASSOCIATES, PC Financial Policy Effective September 1, 2014 Patient name: Account# Ear, Nose and Throat Associates, PC, believes that in the interest of good health care practices,
Patient Registration
Today s : Patient Registration Name: (First, MI, Last) of Birth: Age: Gender: M F Marital Status: S M D W Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: Email Address: Preferred Daytime
Last Name _ First Name Middle Initial _ Social Security Number: Birthdate Age Sex (Circle one) M F Address _City State Zip Home Phone # Cell Work
Last Name _ First Name Middle Initial _ Social Security Number: Birthdate Age Sex (Circle one) M F Address _City State Zip Home Phone # Cell Work Marital Status (circle one) Single Married Separated Divorced
Dear Patient: APPOINTMENT DATE IS: TIME: We look forward to seeing you and providing your eyecare for years to come. Thank you,
Lawrence D. Castleman, M.D. John M. Ramocki, M.D. Snigdha Singh, M.D. James R. Valice, M.D. Dear Patient: Please fill out the enclosed paperwork and bring it to your exam along with your insurance cards.