Patient Demographic Information

Transcription

1 Patient Demographic Information Write your name as it appears on your insurance card. Please complete this form in its entirety Name: Male Female Date of Birth: Primary Insurance: Secondary Insurance: SSN #: Member ID#: Member ID #: BIN For Tricare: Mailing Address: Primary Phone: City/State: Secondary Phone: Emergency Contact Name/Phone: Employer Name/Phone: Address For Patient Portal: Primary Care Doctor & City/State: How Did You Hear About Us? Marital Status: Single Married Divorced Widowed Preferred Language: English French Italian Japanese Portuguese Russian Spanish Race: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Ethnicity: Hispanic Not Hispanic Please be advised: While a refraction is necessary for a patient to receive a prescription for glasses or contact lenses, Medicare and some other insurances will not cover the refraction fee. The charge at Island Eye Care is $ Depending on your insurance plan, you may be responsible for the refraction fee in addition to any applicable co-insurance payment for the office visit.

2 MEDICAL INFORMATION RELEASE AUTHORIZATION I authorize the release of my medical information to my current insurance company to determine any benefits that are payable for the related services from each visit. In addition, I authorize my insurance to pay Island Eye Care for services rendered at the date of service. I accept responsibility for all services not covered by my insurance, including routine vision exams, that are performed by Island Eye Care. Printed name of patient Date Signature of patient Date Island Eye Care 231 SE Barrington Dr. Oak Harbor WA Phone: (360) Fax: (360)

3 Financial and Payment Policy We would like to say thank you for choosing Island Eye Care! We want to inform you of our policies and work with you regarding payments for services rendered: In order to bill your insurance company, we must obtain complete information about your primary and supplemental insurance plans, including a copy of your insurance cards. Due to the frequent changes in the specifics of each individual health insurance plan, Island Eye Care cannot guarantee confirmation of your coverage or benefits by your insurance company. All co-payments are set by your insurance companies and payment is expected at time of service. Payment in full is expected when services are rendered unless other specific arrangements are made in advance with our office. For your convenience, we accept cash, personal checks, and major credit cards including, Visa, MasterCard, American Express, and Discover. We can also help you to secure financing from a third party health care lender. If your insurance carrier requires a referral or authorization for your visit, it is your responsibility to make sure that our office receives current valid authorization. We do not participate with Washington Mediciad. If you have a managed plan such as Apple Health, DSHS, Amerigroup or Community Health Plan of Washington, they are considered Medicaid plans and are not accepted. Returned checks are subject to a $40 service charge. Non-Payment We do send statements after receiving insurance explanation of benefits. Payment is expected upon receipt of statement. Any balance greater than 120 days is considered delinquent. If any account becomes delinquent Island Eye Care reserves the rights to have a collection agency take over the account. If any account is placed with a collection agency, the patient will be responsible for all costs of collection and any legal proceedings. Outstanding balances greater than 120 days may be subject to a 3% late fee. We will work with all patients to ensure that your medical care comes first and foremost. If you have any questions about our financial policy, outstanding balances, or your insurance reimbursement, please contact our office. A detailed version of this policy will be provided upon request. Please sign and date this form, acknowledging that you have read and understand our financial policy. Signature of patient: Date:

4 Permission to Disclose Information Patient Name: Patient Date of Birth: Patient Address: I give my consent to Island Eye Care to disclose my person health information, treatment(s), appointment details, and payment information to the following person(s) listed below: Name: Relationship: Name: Relationship: Name: Relationship: Island Eye Care may leave a detailed message on my answering machine regarding current and future appointment that I have scheduled. YES NO Island Eye Care may send me an to my personal address that I provided regarding my personal health information, treatments, appointment details, and payment information. YES NO I understand that I may change, suspend, terminate, and revoke any person from this list at any time, in writing. Furthermore, I acknowledge that Island Eye Care will NOT disclose any information to anyone who is not on this list. Signature of patient Date

5 Authorization to Release Medical Records Please complete this form in it's entirety Patient Name: Street Address: Date of Birth: Phone Number: City/State/Zip Code: Purpose of disclosure: Personal Transfer of Eye Care Primary Care Provider Insurance Other: Medical Records to be released from: Facility Name: Facility Address: Phone Number:_ Doctor Name: City/State/Zip Code: Fax Number: I authorize the above named facility to release the following health care information: Summary of all visit/chart notes from date: to date: All medical records (diagnostic tests included) All health care information in my medical record Health care information in my record relating to the following treatment or condition: Other: Health Care Information to be released to: Dr. Robert Johnson MD Island Eye Care 231 SE Barington Dr Ste 208 Oak Harbor, WA Phone: Fax: This authorization will expire 90 days after date signed. I hereby authorize disclosure and release of my health information to Dr. Robert Johnson / Island Eye Care. I understand that I may revoke this request at any time in writing, but it will not effect any information released prior to my notification of cancellation. Printed name of patient Date Signature of patient or legally authorized representative Date

6 Digital Retinal Imaging Island Eye Care would like to offer you a digital retinal image that aids in the early detection of diseases that can affect both your eyes and overall health. This digital image captures a picture of the retina, blood vessels, and the optic nerve at the back of the eye. The retinal image obtained provides the doctor with a baseline of information pertaining to the health of your eyes. Additionally, it can assist in the early detection of glaucoma, diabetes, high blood pressure, and macular degeneration. Most insurance companies do not pay for the cost of the digital retinal image when it is used as a screening tool. Island Eye Care recommends you consider this retinal image if you have a family history of glaucoma, diabetes, hypertension, or macular degeneration. The cost for the digital screening photo is $ If you would like to have this voluntary digital retinal image performed during your exam, please sign below. There will be a $40.00 charge that will be collected after your visit. Printed name of patient Signature of patient Date

7 Please list ALL prescribed, over the counter (OTC), vitamins and supplements you currently take. Medication Name Dose How often do you take medication? Why do you take this medication? I do NOT take any Medications/ Over the counter/ Vitamins/ Supplements Printed name of patient Signature of patient Date Island Eye Care 231 SE Barrington Dr. Oak Harbor WA Phone: (360) Fax: (360)

8 Current Review of Systems: Please mark all that apply Patient Name: Date: Family History: NO FAMILY HISTORY Diabetes TB Glaucoma Arthritis Cancer Kidney Disease Macular Degeneration Lazy Eye Heart Disease Blindness Retinal Disease Cataracts High Blood Pressure Stroke Eyes: Decreased Vision New Flashes Old Flashes New Floaters Old Floaters Tearing Dry Eyes Redness Irritation Contact Lens Constitutional: Fatigue Fever Weight Gain/Loss Ear, Nose, & Throat: Hard of Hearing Ringing in Ears Vertigo Ear Ache Cough Dry Mouth Psychiatric: Anxiety Depression Insomnia Cardiovascular: Chest Pain Fainting High Blood Pressure Rapid/Irregular Heartbeat Respiratory: Shortness of Breath Congestion Wheezing Asthma Gastrointestinal: Heartburn Nausea/Vomiting Diarrhea Constipation Urinary: Pain/Difficulty Urinating Blood in Urine History of Kidney Stones Incontinence Musculoskeletal: Stiffness Arthritis Joint Pain/Swelling Neurological: Headache Seizures Paralysis Stroke Tremors Integumentary: Rash Headache Easy Bruising Lymphatic: Bleeding Anemia Heavy Aspirin Use Immunologic: Hives Rashes Hay Fever Runny Nose ALL SYSTEMS NORMAL Previous Surgeries: