Drs. Lawaczeck, McKinnon, Feagin, Carter, & Gee, P.C PATIENT REGISTRATION

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1 Drs. Lawaczeck, McKinnon, Feagin, Carter, & Gee, P.C PATIENT REGISTRATION Patient Name. Today s Date FIRST MIDDLE LAST Home Address City State Zip Code Daytime PhoneSecondary/ Cell Phone Date of Birth Age Gender: M F Social Security Number Marital Status: Single Married Divorced Widowed Employed Student Retired Employer/Parent s Employer Occupation Work Phone Spouse name (Parent name if minor) Spouse/Parent Work Phone Person to notify in case of emergency (other than spouse) Phone number (s) Relationship Referred by: Primary Care doctor: Primary Care Phone: Primary Insurance Company Social Security Number Date of Birth Employer Secondary Insurance Company Social Security Number Date of Birth Employer Tertiary Insurance Company

2 MEDICAL HISTORY QUESTIONNAIRE CHART# Name: Date of Birth: Age: Date: Height: Weight: Sex: Male / Female CONDITIONS: Circle any and all conditions that apply to you or check none. NONE GENERAL: EARS, NOSE, THROAT: CARDIOVASCULAR: RESPIRATORY: fever, heat stroke, weight loss, weight gain, fatigue, insomnia, headaches hard of hearing, ear ache, cough, dry mouth, sinus/allergy, hoarseness, vertigo high B/P, heart attack, chest pain, congestive heart failure, racing pulse, high cholesterol, irregular heartbeat, palpitations, pace maker congestion, wheezing, short of breath, asthma, COPD, emphysema, TB exposure GASTROINTESTINAL: stomach upset, diarrhea, constipation, hernia, ulcers, nausea, GERD, GENITOURINARY: FEMALES: MUSCULOSKELETAL: painful/ frequent urination, blood in urine Are you pregnant? Are you nursing? impotence, yellow jaundice, kidney stones, joint pain, stiffness, swelling, cramps, fibromyalgia, rheumatoid arthritis, lupus, other type arthritis, osteoporosis DERMATOLOGIC: pimples, acne, warts, growths, rash, rosacea, melanoma NEUROLOGICAL: PSYCHIATRIC: anxiety, depression, ENDOCRINE: numbness, headache, seizures, paralysis, stroke, dementia, memory loss, Alzheimer s, Parkinson s diabetes, hypothyroid, hyperthyroid, hormone, increased thirst, Graves Disease, Thyroid Eye Disease HEMATOLOGY: bleeding, anemia, blood clots, problems related to blood transfusions, ALLERGIC/IMMUNOLOGIC: sinus, sneezing, swelling, redness, itching, hives, lupus, HIV, Herpes Simplex Virus, Sjogren s Syndrome, rheumatoid arthritis, CANCER: breast, prostate, lung, skin, colon, other EYES: List all Eye Surgeries & Laser Eye Surgeries: cataract, glaucoma, detached retina, blindness, lazy eye, eye injury/trauma, corneal problems, macular degeneration List all OTHER surgeries you have had: FAMILY HISTORY: Has any member of your immediate family (blood relatives) have/had these diseases? Disease/Condition Family Member Disease/Condition Family Member Diabetes yes no Mother Father Sibling Grandparent Heart Disease yes no Mother Father Sibling Grandparent Macular Degeneration yes no Mother Father Sibling Grandparent Hypertension yes no Mother Father Sibling Grandparent Blindness yes no Mother Father Sibling Grandparent Stroke yes no Mother Father Sibling Grandparent Retinal Disorders yes no Mother Father Sibling Grandparent Thyroid Disease yes no Mother Father Sibling Grandparent Cataracts yes no Mother Father Sibling Grandparent Arthritis yes no Mother Father Sibling Grandparent Glaucoma yes no Mother Father Sibling Grandparent Cancer yes no Mother Father Sibling Grandparent Lazy Eye yes no Mother Father Sibling Grandparent Type of Cancer: Mother Father Sibling Grandparent Physician Signature: Date: All information you provide is confidential and will not be released to anyone without your consent Use back of form for any additional information that you need to add.

3 MEDICAL HISTORY QUESTIONNAIRE Patient Name: Date: CHART# SOCIAL HISTORY: ( Circle:) Student Homemaker Employed Retired (Circle:) Single Married Separated Divorced Widowed Do you use Tobacco? Yes / No Cigarettes / Smokeless # Packs/Times a Day # of Years Do you use Alcohol? Yes / No Rarely Daily Weekly 1-2 drinks 2-4 drinks Other Substance Abuse? Yes / No Rarely Daily Weekly PHARMACY INFORMATION: ( ) Name of Pharmacy Address Phone: LIST ANY DRUG ALLERGIES: List all Prescriptions and Over the Counter medications you are taking: (Including Eye Drops) If you have a list, please give to receptionist to copy in lieu of filling out form: Medication Name Dosage Taken how often? PRN= when needed Route Reason for taking Currently Taking Yes No REVIEWED: Staff Date Physician Signature: Date: All information you provide is confidential and will not be released to anyone without your consent Use back of form for any additional information that you need to add.

4 AUTHORIZATION FOR USE OF DISCLOSURE OF PROTECTED HEALTH INFORMATION: Name: Date of Birth: May we leave messages/detailed medical information on voic at either of these phone numbers? Yes No Day Phone: Yes No Cell Phone: May we contact you at your place of employment? Yes No If so, may we leave a message? Yes No Do you have any particular person or family members that you authorize to receive and discuss information regarding your personal health information (general information, surgical and billing)? Yes No If yes, please provide: Name: Relationship: Phone: Is this person your Power of Attorney for medical purposes? Yes No Name: Relationship: Phone: Is this person your Power of Attorney for medical purposes? Yes No --If no one is listed above, protected health care information will not be disclosed except in those situations described in the Notice of Privacy Practices. This authorization remains in effect until revoked.-- I hereby authorize Drs. Lawaczeck, McKinnon, Feagin, Carter, Gee and Dahl and/or administrative and clinical staff of to obtain or release any and all pertinent information regarding my medical care, as needed, to assist in my ongoing treatment to or from other health care providers, laboratories, radiology facilities or other institutions. I have reviewed the 2003 Notice of HIPAA Privacy Policy. A copy of this policy will be provided to me upon request. Patient Signature: Date: Insurance: I certify that I (or my dependent) have insurance medical coverage and agree to have insurance payments made directly to Drs. Lawaczeck, McKinnon, Feagin, Carter & Gee, and P.C. and to be applied to my account for services rendered. All Copayments, Co-Insurance, self-pay visits, deductible and or non-covered services must be paid at the time service is rendered. (We do not accept Vision Plans) For patients covered by Medicare the patient will be responsible for 20% of the Medicare allowable charges plus any deductibles, coinsurance and uncovered charges that apply. Referrals: You are responsible for obtaining a referral if one is required by your insurance carrier. (Medicare Complete, Cigna Healthsprings, United Healthcare with PCP referrals on front of card, are a few that require referrals). If we are participating providers with your carrier, we will file your claim for your office visit or surgery and allow 45days for payment in full. Should payment not be received within 45days, the balance due will become the obligation of the guarantor on the account and must be paid within 30days. Agreement to Pay: As consideration for the Physician s rendering services to the patient, the patient or person responsible for the account agrees to pay all charges for services at the completion of such services. In the event the account is not paid in full within 45days, the Physician, may at his/her discretion, place the unpaid account with an attorney for collection. The patient or person responsible for the account agrees to pay all costs of collection, including reasonable attorney s fees and agrees to pay the legal rate of interest on the account until paid in full and hereby waives all rights of exemption under the Constitution and laws of the State of Alabama. I understand that I am financially responsible for all charges incurred in the event that my insurance denies payment. I am aware there may be additional collection and/or attorney s fees if my account is referred for collection. Patient s signature Today s date Consent to Treat: I hereby consent to the treatment for myself or the above listed patient Patient s signature Today s date

5 Drs. Lawaczeck, McKinnon, Feagin, Carter & Gee, P.C. Alabama Eye M.D Montgomery Highway, Suite 200 Birmingham, AL REFRACTION SERVICES AND FEES Refraction is the process of determining your best corrected vision and if there is a need for corrective eyeglasses or contact lenses. It is an essential part of the eye exam and is necessary to write a prescription for glasses or contact lenses. Refraction is NOT a covered service by Medicare or most medical insurance plans. These plans consider a refraction a vision service not a medical service. We will NOT file the charge for refraction with a health insurance unless we know that your plan covers the refraction charge. Our office fee for refraction is $35.00 and this fee is collected at the time of service in addition to any co-payment your plan may require. Should your plan pay us for the refraction, we will reimburse you accordingly.. Patient s Name (printed) Date Patient Signature (Legally responsible applicable) Relationship to patient Staff Witness

PATIENT REGISTRATION PLEASE PRINT LAST NAME FIRST NAME MI. Date of Birth Age SS#

PATIENT REGISTRATION **PLEASE PRINT** LAST NAME FIRST NAME MI. Date of Birth Age SS# PATIENT REGISTRATION of Birth Age SS# Primary Physician Previous Eye Doctor How did you hear about us? q Yellow Pages q Church Bulletin q Advertisement q Internet q Friend/Family q Referring Doctor Patient's