Subscriber of Insurance (if different from Guarantor)

Transcription

1 Patient Registration Patient s Name (First) (MI) (Last) (Nickname) Gender (CIRCLE ONE) Male Female Birth Date / / Patient SSN Address: City State Zip Patient s Employer: Position Marital Status Married Single Widowed Divorced Ethnicity Hispanic Caucasian African American Asian Other Primary Care Physician Referring Physician Referring Eye Doctor Preferred Pharmacy City Name of Street or cross road Phone#: PREFERRED METHOD OF CONTACT (CIRCLE ONE) OR PHONE Primary Phone (M)(H)(W) Secondary (M)(H)(W) Third (M)(H)(W) Address Emergency Contact _Relationship Phone Emergency Contact s Address (if different from above) Guarantor Guarantor Name: DOB / / SSN Guarantor s Address (if different from above) City _ State Zip Code Employer Position Subscriber of Insurance (if different from Guarantor) Subscriber Name: DOB / / SSN Subscriber Address (if different from above) City _ State Zip Code Employer Position Please Tell Us How You Heard About Us Internet Advertisement Insurance Provider Friend /Relative: (who) Doctor:

2 Medical History Form Patient Name Past Ocular History O cataracts O glaucoma O macular degeneration O other eye conditions O prior eye surgeries (specify eye and date) Past Medical History O diabetes O hypertension O elevated cholesterol O heart disease O thyroid disease O gastric reflux/ulcer O other Past Surgical History O cardiac cath/stent O cardiac bypass O cardiac pacemaker O thyroid removal O appendix removal O gallbladder removal O other Medications (for eye drops, list which eye and frequency) O no medications Allergies O no known drug allergy Social and Family History Alcohol O none O occasional O daily Smoking O never O former O occasional O daily Family history of: O glaucoma O macular degeneration O keratoconus Review of Systems Eyes O eye pain O tearing O redness O vision loss O poor vision Constitutional O fevers O chills O weight loss ENT and Mouth O stuffy nose O cough O ear ache O dry mouth Cardiovascular O high blood pressure O rapid heart beat Respiratory O congestion O wheezing O shortness of breath Gastrointestinal O upset stomach O diarrhea O constipation Genitourinary O burning on urination O urinary frequency O incontinence Musculoskeletal O joint pain O stiffness O arthritis Integumentary/Skin O rash O changing moles Neurological O headache O seizure O stroke O paralysis Psychiatric O anxiety O depression O insomnia Endocrine O diabetes O thyroid abnormalities Hematologic/Lymphatic O bleeding O anemia Allergic/Immunologic O allergies O hay fever O hives

3 Ajit Nemi, MD, MBA Notice of Privacy Practices- HIPPA policy information I, (Print Patient Name), have been notified of Dr. Nemi s privacy policies and procedures. I understand a copy of the policies and procedures will be provided to me upon request. Permission to Leave Messages I, (Print Patient Name), give permission for messages to be left regarding my private health information on the following phone numbers: Home: Mobile: Permission to Discuss Private Health Information I, (Print Patient Name), give permission to discuss my private health information with the following person(s). Name: Name: Name: Name: 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. It is not possible for your ophthalmologist to predict how much your vision will be affected. Because driving may be difficult immediately after an examination, it is best to make arrangements if you are not comfortable driving. Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. I hereby authorize Dr. Nemi and/or such assistants as may be designated to administer dilating eye drops. The eye drops are necessary to diagnose my condition. Patient/Guardian Signature: Date: Witness Signature:

4 LOTUS VISION FINANCIAL POLICIES Billing Medical vs. Vision Insurance Though we are willing to verify your insurance coverage for you, we do so as a courtesy. Ultimately you are responsible for any remaining balance that your insurance company denies or deems as a non-covered service. To insure that you receive proper coverage, please contact your insurance company. Although the examination that you receive may be the same or similar to previous visits, the reason for the exam and the doctor s diagnosis dictate how we must bill our patients. Medical insurance will be billed for all medical concerns such as cataracts, blurry vision, dry eyes, redness, headaches, and/or issues related to a medical eye condition. Vision insurance may offer to pay for a portion of a routine healthy eye exam when your doctor checks your vision, analyzes your eyeglasses/ contact lens prescription and evaluates your entire eye health. It may also cover some of the cost of materials, such as eyeglasses or contact lenses. Medicare Patients: We will bill Medicare for you. All co-payments or deductibles are due and payable at the time service is provided. At the beginning of each calendar year, you may receive a statement for any remaining co-payments, coinsurance, or deductibles you may owe. Signature on file: I,, request payment of authorized Medicare benefits be made on my behalf to Lotus Vision, for any services furnished me by the provider. 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 to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of HCFA form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorized releasing of the information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept the charge determination of the Medicare carrier as full charge and the patient is responsible for the deductible, coinsurance, or non-covered services. Coinsurance and the deductibles are based upon the charge determination of the Medicare carrier. Auto Injury Cases: This office does not bill auto insurance for auto accident cases. We do NOT accept liens. Worker s Compensation: If your injury is work-related, we will need the case number and carrier name prior to your visit in order to bill the worker s compensation insurance company. Patients with insurance please read and sign below: I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private and/or auto insurance, and any other health plans, to Lotus Vision. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize an assignee to release all information necessary to secure payment. Please note: All account delinquent past 60 days from date of service will incur a $35 service charge. I have read and understand the above information. I accept full financial for the cost of refraction and/or contact lens fitting in addition to any other eye exam services. I understand that any copay, coinsurance, or deductible I may have are separate from and not included in either the refraction fee, contact lens fitting fee, or other non-covered procedures. SHOULD YOU MISS A SCHEDULED APPOINTMENT WITHOUT PROVIDING AT LEAST 24 HOURS NOTICE YOU WILL BE CHARGED A $20.00 CANCELLATION FEE. Patient/Guardian Signature: Date: Print Patient Name: Witness Signature:

5 Refraction Service and Fee Refraction is how we determine the best visual acuity and assess the overall health of the eyes. It provides essential information for the physician during the evaluation, especially new patient examinations, regardless of the nature for the visit. Refraction requires specialized equipment and is performed by the doctor or specialty-trained technicians. However, despite its importance, some insurance companies choose not to cover this test. We will collect this fee at the time of your service if we know in advance it is not covered. Please review the chart below to review your fee. Insurance Company Refraction Charge Medicare, Medicaid, Tricare, $30.00 Peachstate, Amerigroup, Wellcare, United Healthcare, Blue Cross Blue Shield, Cigna, Coventry, Humana, and Misc. Insurance Aetna $22.31 For patients who are covered under vision plans EyeMed and VSP, if denied by your medical insurance, we will bill this charge on your behalf to your vision plan. Other vision plans do not cover this fee if the exam is billed medically. Should your insurance plan pay us for refraction, we will reimburse accordingly. I have read and understand the above information. I accept full financial for the cost of refraction and/or contact lens fitting in addition to any other eye exam services. I understand that any copay, coinsurance, or deductible I may have are separate from and not included in either the refraction fee, contact lens fitting fee, or other non-covered procedures. Please note: All account delinquent past 60 days from date of service will incur a $35 service charge. Patient/Guardian Signature: Date: Print Patient Name: Witness Signature:

6 Explanation of Contact Lens Fees Do you wear contacts? Yes / No If not are you interested in contacts? Yes / No If so, what kind? Right Eye: Brand: _ BC (Base Curve): DIA (Diameter) Power: Cylinder (Toric only) Axis (Toric only) Left Eye: Brand: _ BC (Base Curve): DIA (Diameter) Power: Cylinder (Toric only) Axis (Toric only) Contact Type New Wearer Previous Wearer Standard, Soft, Disposable Lenses $50.00 $35.00 Toric or Multifocal Lenses $65.00 $45.00 Rigid Gas Permeable (RGP) Lenses $75.00 $55.00 The Contact Lens Fitting fee includes: Contact Lens Exam Instructions on Insertion and Removal for New Wearers Trial Lenses as Needed w/ Lens Care Kit Follow-up visits as needed for up to sixty (60) days A Contact Lens Fitting is not part of the standard eye examination and may require a number of follow-up visits. This communication is important to ensure the proper fit of the lenses and health of the eyes. The cost of the Contact Lens Fitting is determined by the type of lenses that are required, your prescription, and whether you are a new or previous wearer. If you have never worn contacts before, your fee will fall under the New Wearer column above. If you have worn contacts before, your fee will fall under the Previous Wearer column above. Fitting Fees for Previous Wearers: There still needs to be an evaluation/fitting of the contact lenses themselves with regard to the fit and vision provided with the current contact lenses. A contact lens prescription cannot be given with out evaluation/fitting. The doctor checks to make sure there is no over wear with the contact lens. Contact lenses, regardless of how well they fit or how old they are, reduce the amount of oxygen to the cornea and can increase your risk of dry eyes, inflammation, and infection. If the doctor determines the fit or vision to be unacceptable, a new lens may be required to provide a better fit. A reduced fee is charged for previous wearers. When ordering contact lenses, any copays or amounts due by the patient are payable at the time the order is placed. Every pair is verified and inspected for defects prior to initial dispensing. Any damage incurred after dispensing is the responsibility of the patient. If you would like your purchased contacts to be delivered to you there is an additional fee of $3.00. By state law, contact lens prescriptions are valid for 1 year. Replacement lenses will be dispensed only to those patients whose prescriptions remain valid and have not surpassed the expiration date. A written copy of the contact lens prescription may be released to the patient in accordance with Federal requirements and patient compliance guidelines. Lenses purchased from other sources or suppliers will not be warranted for defects. It is the patient s responsibility to ensure that all lenses purchased from another supplier meet the exact specifications as prescribed by our office. These charges cover specific services and will be in addition to other eye examination service charges, including co-pays that you may incur during your visit today. Please Note: All accounts delinquent past 60 days from date of service will incur a $35.00 service charge. Patient/Guardian Signature: Date: Print Patient Name: Witness Signature: