RELEASE OF MEDICAL INFORMATION
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1 Lawrence M. Levine, M.D. P. Vernon Jones, M.D. David W. Hayes, D.O. David A. Green, O.D. Melanie C. Javier, O.D. RELEASE OF MEDICAL INFORMATION I hereby authorize the release of any and all medical records pertaining to my care to: Clay Eye Physicians & Surgeons C.M. Harris, M.D. John D. Wilcox Jr., M.D. John P. Donovan, M.D. Donald M. Downer, M.D. Russell A. Pecoraro, M.D. Lawrence M. Levine, M.D. P. Vernon Jones, M.D. David W. Hayes, D.O. David A. Green, O.D. Melanie C. Javier, O.D. If we are unable to reach you personally, do we have your permission to leave a message on your voice mail or answering machine? YES NO When calling our office regarding your care or to request prescription medication, please keep in mind that we need to speak to you directly. This will ensure that both parties receive the correct information. Also, I give my permission for Clay Eye Physicians & Surgeons to release my medical information to the following people: Name/Relationship to Patient I understand that by signing this form, I have authorized this office to release my medical information. Patient Name: Patient Signature: Date: MR /16
2 CLAY EYE PHYSICIANS & SURGEONS NAME: DOB: DATE: MEDICATIONS AND ALLERGIES: Please attach medication list if available. Medication or Vitamins Name Dosage Reason for taking DRUG ALLERGIES REACTION MA /12
3 Lawrence M. Levine, M.D. P. Vernon Jones, M.D. David W. Hayes, D.O. David A. Green, O.D. Melanie C. Javier, O.D. DATE: MARITAL STATUS: qm qw qs qd PATIENT NAME: DOB: ADDRESS: AGE: SEX: CITY: STATE: ZIP: SSN: HOME PHONE: ALT PHONE: EMPLOYER: WORK PHONE: MAY WE CONTACT YOU VIA ? qyes qno ADDRESS: ARE YOU A VETERAN? qyes qno DRIVER S LICENSE #: PARENT/SPOUSE NAME: PARENT/SPOUSE DOB: PARENT/SPOUSE SSN: WORK PHONE: EMERGENCY CONTACT: PHONE: PRIMARY INSURANCE NAME: ID# PRIMARY CARD HOLDER NAME: DOB: RELATION: SECONDARY INSURANCE NAME: ID# SECONDARY CARD HOLDER NAME: DOB: RELATION: IS THIS ACCIDENT OR INJURY RELATED TO: qauto qjob qother DATE OF INJURY: PRIMARY CARE PHYSICAN: PHONE: PHARMACY: PHONE: TO BE IN COMPLIANCE WITH FEDERAL GUIDELINES, PLEASE INDICATE WHICH OF THE FOLLOWING BEST DESCRIBES YOU: RACE: q American Indian or Alaska Native q Asian q Black of African American q More than one race q Native Hawaiian or Pacific Islander q White q Other q Unknown/Not Reported ETHNICITY: qhispanic or Latino q Not Hispanic or Latino q Unknown/Not Reported PRIMARY LANGUAGE: HOW DID YOU HEAR ABOUT CLAY EYE PHYSICIANS & SURGEONS? (check all that apply) q Referring Physician: qfriend/family: qhospital Consult qwebsite qhealth Fair qinsurance Referral qemergency Room Consult qprint Ad q Other: PH /16
4 Lawrence M. Levine, M.D. P. Vernon Jones, M.D. David W. Hayes, D.O. David A. Green, O.D. Melanie C. Javier, O.D. Office Agreement and Consent Form Payment is due when services are provided. We accept Cash, Check, Visa, Mastercard, Discover, American Express, Care Credit and Alphaeon Credit cards. There is a $45 handling fee for any returned check. Medical/Vision Insurance: As a courtesy to you, we will file your claim if we are a Provider for your insurance plan. At the time of your exam you will be responsible for co-payments, deductibles, co insurance, a $49 refraction fee (if necessary), and any non-covered charges. After 90 days any remaining balances will become patient responsibility and billed to you directly. Following the mailing of your second statement a charge of $15 will be attached to your account for any remaining balances. It is your responsibility to inform us of any changes in your insurance carrier or policy. It is also your responsibility to obtain proper referral/authorization for your visit with us. We may provide some assistance to help obtain the proper authorization. If a referral cannot be obtained for your visit, you will be considered a self pay patient. Self pay patients are responsible for all service fees at time of service. Our treatment is based on the needs of the patient, not the insurance company benefits. We cannot render services to a patient on the assumption that the charges will be paid by the insurance company, nor can we know every service not covered by your insurance company. After Hours Care: If you should require our services after regular business hours, please understand that there is an additional fee not covered by insurances. This fee of $100 will be billed directly to you. Collection Fees: If your account becomes delinquent and is submitted to a collection agency, you will be responsible for an additional 35% collection fee. Both the prior balance and the collection fee will need to be paid in full before the practice will see you again. Refraction: A $49 fee is charged for the performance of the refraction. A refraction is performed to determine your best-corrected vision to distinguish medical eye problems from a simple need for glasses. Most medical insurance plans, including Medicare and Tricare for Life, do not cover routine eye examinations and they do not consider the refraction to be a part of a medical eye exam. When a refraction is performed, our office will collect your refraction charge along with any copayment and deductible due at the time of service. I authorize release of any information, records and testing to offices where I have been referred. Consent: The undersigned hereby authorizes Clay Eye Physicians and Surgeons to perform treatment based on the needs of the patient. I authorize the doctor to perform any and all forms of treatment, medication, and therapy, that may be indicated in connection with the patient and further authorize and consent that the doctor choose and employ such assistance as deemed fit. I have read and understand the above policy. Name (Printed) Signature Date Patient s Name (If you are not the Patient) Relationship to Patient Date FP500B rev2/16
5 Clay Eye Physicians & Surgeons P.A. Fleming Island Optical Notice of Privacy Practices for Protected Health Care Information This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Get Access To This Information. Please Review It Carefully. Our goal is to take appropriate steps to attempt to safeguard any medical or other personal information that is provided to us. The Privacy Rule under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) requires us to: (i) maintain the privacy of medical information provided to us; (ii) provide notice of our legal duties and privacy practices; and (iii) abide by the terms of our Notice of Privacy Practices currently in effect. Who Will Follow The Notice The notice describes the practices of our employees and staff as well as any individuals and/or business entities associated with Clay Eye Physicians. In addition, these individuals, entities, sites and locations may share Medical Information with each other for treatment, payment and health care operation purposed described in the notice. Information Collected About You In the ordinary course of receiving treatment and health care services from us, you will be providing us with personal information such as: Your name, address, and phone number. A valid picture ID. Information relating to your medical history Your insurance information and coverage. Information concerning your doctor, nurse or other medical providers. In addition, we will gather certain medical information about you and will create a record of the care provided to you. Some information also may be provided to us by other individuals or organizations that are part of your circle of care such as the referring physician and your other doctors, your health plan and close friends or family members. We have available upon your request a copy of the Federal Guidelines and listing of all types of persons, entities, and/or situations in which we might disclose your personal health care information. I have received a one -page summary outlining the Privacy Rules under the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ). I acknowledge receipt of this summary as well as the availability upon my request of a copy of the Federal Guidelines. Patient/Responsible Party Date HIPAA-2010
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(Please Print using Black or Blue Ink) SEX: GENDER IDENTITY: MARITAL STATUS: SINGLE MARRIED OTHER
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Continued on Reverse Side
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NO-FAULT PATIENT INFORMATION *** PLEASE COMPLETE ALL INFORMATION REQUESTED FOR OUR RECORDS *** Date:
NO-FAULT PATIENT INFORMATION *** PLEASE COMPLETE ALL INFORMATION REQUESTED FOR OUR RECORDS *** Date: Last Name: MI: First Name: DOB : SEX : SS # : Address: City: State Zip Code: Phone (Home): Phone (Cell):
HOME ADDRESS APT. NO CITY STATE ZIP CODE S M D W PRIMARY INSURANCE INFORMATION SUBCRIBER S FIRST NAME LAST NAME RELATIONSHIP TO PATIENT DATE OF BIRTH
PATIENT REGISTRATION FORM PATIENT NAME LAST FIRST MIDDLE INITIAL PATIENT DATE OF BIRTH HOME ADDRESS APT. NO CITY STATE ZIP CODE OCCUPATION EMPLOYED RETIRED STUDENT SOCIAL SECURITY # MARITAL STATUS S M
FINANCIAL POLICY AND AGREEMENT
FINANCIAL POLICY AND AGREEMENT Our office is committed to providing excellent, affordable medical care. You have the right and responsibility of knowing the cost of your medical treatment. Should you be
West Cary Family Physicians 256 Towne Village Dr Cary, NC
New Patient Registration Form - page 1 PATIENT INFORMATION Patient s first name: Patient s middle name: Patient s last name: Patient date of birth: Patient sex: Marital status: single married Patient s
Employer/Doctor Employer s Name Address: Referring Doctor Phone Number Primary Doctor Phone # Patient Information
FINANCE INSURANCE ORTHOPEDIC SPINE AND SPORTS MEDICINE CENTER 2 FOREST AVEPARAMUS, NJ 07652 PATIENT QUESTIONAIRE Patient s Name: Last First (legal): Middle Initial: Address: City: State: Zip: Date of Birth:
Referring Physician: Primary Care Physician: Other Physician(s)/Specialty: EMERGENCY CONTACT INFORMATION INSURANCE INFORMATION
PATIENT INFORMATION Name: Date of Birth: Sex: Male Status: Single Married Divorced Widowed Other 502 Elm Street NE Language: Female Race: American Indian or Alaska Native Native Hawaiian or Or Pacific
Patient Registration WELCOME TO OUR OFFICE
Patient Registration WELCOME TO OUR OFFICE Date of Birth: Home Address: Apt / Unit: City: State: Zip: SSN: Telephone: Home: Cell: Work: Email: Marital Status: Name of Spouse / Partner: Preferred method
REGISTRATION FORM. Physician (PCP): PATIENT INFORMATION. Last Name: First Name: MI: Billing Address: City: ST Zip Code:
: REGISTRATION FORM Physician (PCP): PATIENT INFORMATION Last Name: First Name: MI: Social Security #: DOB: Sex: M F Billing Address: City: ST Zip Code: Home Phone#:( ) Cell Phone#:( ) Work Phone#:( )
Accessible, Affordable, Quality Patient Centered Medical Home
PATIENT REGISTRATION Child :Last Name: First Name: MI: D.O.B.: / / Sex: Primary Language: Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / Black / Hawaiian / White Primary Policy: Policy Holder
Pediatric & Adolescent Center of NW Houston, PA & Northwest Houston Neurology, PA
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Patient Registration
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COREY M. NOTIS, M.D., P.A.
COREY M. NOTIS, M.D., P.A. Registration Form Last Name: First Name Address: City: State: Zip Code: Home Phone: Work Phone Cell Phone: Date of Birth: Social Security # Emergency Contact Name: Phone #: Occupation:
Patient Registration Forms
Patient Registration Forms PATIENT INFORMATION First Name: Middle: Last: DOB: / / Sex: M/F Primary Language: Address: City: ST ZIP Ethnicity: Hispanic / Non-Hispanic / Unknown Race: Asian / White / African
EyE CEntEr Paul V. Minotty, MD. Vision/Lifestyle Questionnaire. Name Date of birth
/Lifestyle Questionnaire Date of birth In addition to gaining clearer vision after cataract surgery, patients today have more of a choice in their visual outcome. This is achieved by replacing the clouded
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ELYSE S. RAFAL, F.A.A.D.
ELYSE S. RAFAL, F.A.A.D. Welcome to our practice. Thank you for placing your trust in us. We look forward to serving you with quality and compassionate care. Patient Information Today s : First Name: M.I.
Please provide the office with a copy on your next visit
Please provide the office with a copy on your next visit Physician Information (Include first AND last name of physician) Who referred you to our office? Phone Who is your primary care physician? Phone
PATIENT REGISTRATION FORM
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Gary W. White, M.D. Dean A. Cione, M.D. Jeremy S. Carrasco, M.D. Ramsey A. Stone, M.D
PATIENT REGISTRATION FORM First Name: MI: Last Name: Date of Birth: Address: Apt#: City: State: Zip: Home Phone: ( ) Cell Phone: ( ) Work Phone ( ) SS#: - - SEX: Female Male E-mail Address: Ethnicity:
PATIENT INFORMATION DEMOGRAPHICS. First Name Middle Initial Last Name Gender. Mailing address: Apt # City: State: ZIP Code: Home Phone Cell Phone
PATIENT INFORMATION Gary S. Fields, DPM, FACFAS Kenneth M. Danis, DPM, FACFAS DEMOGRAPHICS First Name Middle Initial Last Name Gender SSN Birthdate Age Email M F Mailing address: Apt # City: State: ZIP