Lawrence Eye Care Associates, P.A.
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- Marvin McLaughlin
- 5 years ago
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1 Dear Patient: Enclosed you will find paperwork that you will need to complete and bring with you on the day of your scheduled appointment. You will only need to complete this paperwork if you are a new patient or if you have not been treated since September, This will expedite the registration process so that we can get you back to see the physician as soon as possible. Please have your insurance card and driver s license or ID card with you so that we can take a copy for our records. If your insurance requires that you pay a co-pay, we will collect that prior to your seeing the doctor. In addition to a co-pay, if your insurance requires that you have a referral from your primary care physician, the referral must be in place before you see the physician or we will need to reschedule the appointment. Our goal is to make your visit go as smoothly as possible. If you have any questions prior to your scheduled appointment, please don t hesitate to call us at between the hours of 8:00am 4:30pm, Monday through Friday. Sincerely, Lawrence Eye Care Associates, P.A. Lawrence Eye Care Associates, P.A W. 6th St., Suite 214 Lawrence, KS Office: (785) Fax: (785)
2 PATIENT INFORMATION LAWRENCE EYE CARE ASSOCIATES, P.A. FULL NAME DOB / / SSN ADDRESS CITY ST ZIP CELL PHONE ( ) HOME PHONE ( ) WORK ( ) GENDER: M F MARITAL STATUS SPOUSE NAME *EMERGENCY CONTACT RELATIONSHIP PHONE *Emergency contact will be used for emergencies only and is NOT authorized for release of information. RACE: African American Asian White Other ETHNICITY: Hispanic/Latino Not Hispanic/Latino Other EMPLOYER PHONE OCCUPATION PRIMARY INSURANCE INS NAME POLICY HOLDER RELATIONSHIP DOB / / SSN INS ID# GRP # SECONDARY INSURANCE INS NAME POLICY HOLDER RELATIONSHIP DOB / / SSN INS ID# GRP # RELEASE OF INFORMATION (VERBAL ONLY) I authorize Lawrence Eye Care Associates, P.A. to communicate with regarding my patient information. IF THE PATIENT IS A DEPENDENT OR STUDENT, PLEASE PROVIDE THE FOLLOWING: RESPONSIBLE PARTY NAME RELATIONSHIP DOB / / SSN PHONE ( ) ADDRESS CITY ST ZIP PATIENT SIGNATURE DATE / / Rev. 01/2018
3 INSURANCE / PAYMENT AUTHORIZATION PATIENT NAME DOB / / INSURANCE PAYMENT AUTHORIZATION I authorize Lawrence Eye Care Associates, P.A. and its representatives to file my primary and secondary insurance and receive payment for services rendered. I also understand that I am responsible for 100% of any balance that is not paid or covered by my insurance. PATIENT PAYMENT AUTHORIZATION I understand that if I do not have insurance or if Lawrence Eye Care Associates, P.A. is not a provider with my insurance, I will be responsible for 100% of any balance that is not paid or covered by my insurance. Our practice is NOT contracted with Medicaid Insurance and we do NOT accept vision plans. The following plans will NOT be accepted: Amerigroup Kancare, United Healthcare Kancare, Sunflower Kancare, Traditional Medicaid, All Vision Plans. The Optical Shop will ONLY accept Traditional Medicare (Red/White/Blue Card) after cataract surgery. NOTICE OF PRIVACY PRACTICES The Notice of Privacy Practices for Lawrence Eye Care Associates, P.A. was made available to me on the date of this signed authorization. BENEFICIARY OR AUTHORIZED SIGNATURE DATE / / Rev. 01/2018
4 LAWRENCE EYE CARE ASSOCIATES, P.A. Patient Name Date of Birth Health Care Providers Referring Doctor Phone # ( ) Primary Care Doctor Phone # ( ) Eye Care Doctor Phone # ( ) Preferred Pharmacy & Location Mail Order Pharmacy Reason for Today's Visit q blurry spot in vision q discharge q injury q glaucoma evaluation q red eye(s) q blurry vision q distorted vision q flashes q headaches q burning sensation q bump on eyelid(s) q dizziness q floaters q itchy eyelid(s) q pain in eye(s) q loss of vision q double vision q dry eye(s) q itchy eye(s) q swelling q crossed eyes q droopy lid(s) q glasses re-check q glare q other (please explain) q wishing to be free of glasses or contacts q foreign body sensation q eyelashes turning in q diabetic eye exam Severity: q Minimal q Mild q Significant q Moderate q Severe Location: q Right eye q Left eye q Both eyes q Other: Timing: q None q Intermittently q Constantly q Occasionally q Once This has been going on for: Hours Days Weeks Months Additional Comments
5 *Allergies: q None q Latex q Other: q Eye drops q Medication q Food Vision History Previously Diagnosed q None Previous Eye Surgeries (include year and surgeon) Current Eye Drops Prescription & Over the Counter q Cornea Disease q None q None q Cataracts q Cataract q Artificial Tears times a day q Glaucoma q Glaucoma q Gel drops times a day q Crossed or Lazy eye q Retina q Ointment times a day q Dry Eye q Laser q Other: q Macular Degeneration q Diabetic Retinopathy q Other: q Refractive q Injury q Other: Current Eye Vitamins: (list brand) Medical History Previously Diagnosed (Include Year) Past Surgeries (include year) Current Medications (include dosage and vitamins) q None q None q None q Diabetes q q q Plaquenil Treatment q q q Thyroid Problems q q q Prostate Problems q q q q q
6 Family History Has anyone in your family (blood relatives) had any of the following? q macular degeneration q cancer q heart disease q glaucoma q diabetes q High blood pressure q stroke q kidney disease q retinal disease q cataracts q crossed or lazy eye q arthritis q blindness q TB q Other: Social History Smoking Alcohol Drugs q Never smoked q Never q Never used q Current every day smoker q Daily q Current every day user q Current some day smoker q Occasionally q Current some day user q Former smoker q Seldom q Former user Review of Systems
7 MEDICARE SECONDARY PAYER QUESTIONNAIRE Patient Name: DOB: / / Please respond to each of the following: 1. Are you receiving Black Lung Benefits? YES NO 2. Are the services to be paid by a government research program? YES NO 3. Are you entitled to benefits from the Department of Veteran Affairs? (VA) YES NO 4. Is your illness/injury due to any of the following: YES NO Work Related Auto Accident Other 5. Are you covered under any insurance plan through your or your spouse s employer? YES NO Patient Signature Date Rev. 1/2018
Eye Associates of Georgetown, LLPC
Eye Associates of Georgetown, LLPC Paige Quinlivan, O.D. & David Quinlivan, O.D. Mr. Mrs. Ms. Miss. Rev. Dr. Name : (Last) (First) (Mid. Intl.) Nickname: (if any) Address: City: State: Zip Code Cell Phone:
Eye Associates of Georgetown, LLPC
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NOTICE ABOUT REFRACTION
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NOTICE ABOUT REFRACTION
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Welcome to West County Vision Center
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Life is Beautiful. See it! New Patient. Dr. Mr. Mrs. Ms. First name. Last name. Street address. Home Phone Cell Phone Work Phone
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I Federal Law requires us to ask race: Hispanic Non-Hispanic
Today's Date < McCoy VISION Please Contact Me at this Number Patient Registration Chart# - Patient's Name (last, first, middle initial) Date of Birth Sex Home Phone Street Address City State Zip Work
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Preferred Name. Address Zip: Name of Family Physician. Emergency Contact EYE HISTORY. Date of last exam
Name Date of Birth Age Cell Phone Email address Preferred Name Height Weight Male/Female/Other May we leave a message? Yes/No May we email you? Yes/No Address Zip: Employer (or School) Name of Family Physician
Name: (Last) (First) (M.I.) (Nick Name) Address: City: State: Zip: Address:
Date: / / Welcome and thank you for choosing McCabe Vision Center for your eye care needs. We take pride in providing you with the best vision correction possible. : (Last) (First) (M.I.) (Nick ) Address:
Complete Your Personal Information Salutation Mr. Mrs. Ms. Dr. Miss. Master Rev. First Name* Last Name* Preferred Name
Please take a few minutes to complete this Patient Welcome Form before you visit our office for the first time. Print it out, fill it in, and bring the copy with you to your next appointment. Complete
INSURANCE INFORMATION
PATIENT INFORMATION Patient Name: Dr., Mr., Mrs., Miss, Ms. Home Address: City: State: Zip: Reason for Visit: Email: Phone: Date of Birth: Sex: Male Female Social Security No.: Who Referred You: WORK INFORMATION
If you circled married, please complete Spouse s Information below: Spouse s Last Name: First Name:
METROPOLITAN EYE CARE Scott B. Pomerantz, M.D. Thomas J. LoPresti, O.D Lori R. Kaplan, O.D. 523 Forest Avenue Paramus, NJ 07652 Tel. (201) 262-5070 Fax (201) 262-5333 Please Complete and Sign Where Indicated
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Arthur M. Cotliar, M.D. & Staff
Dear Patient: Thank you for taking time to schedule an appointment at one of our offices. Please fill out the enclosed forms and bring the forms with you on the day of your appointment. In addition, please
Dear patient: We welcome you to our practice and ask that you kindly complete or correct all information on this form.
Account No: WELCOME LETTER Dear patient: We welcome you to our practice and ask that you kindly complete or correct all information on this form. PATIENT INFORMATION PATIENT NAME: SEX: LAST FOUR SOCIAL
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 INFORMATION PRIMARY INSURANCE INFORMATION
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PATIENT REGISTRATION. Patient s Name: (Last) (First) Home Address: City State Zip. Home Phone: Cell Phone: Work Phone:
PATIENT REGISTRATION Date: Patient s Name: (Last) (First) Home Address: City State Zip Home Phone: Cell Phone: Work Phone: Email Address: May we call you at work? Yes No Date of Birth: Sex: M / F / Other
New Patient Questionnaire. Patient Full Name: Date: Street Address: City: State: Zip Code: Primary Care Physician: Pharmacy:
New Patient Questionnaire Patient Full Name: Date: Street Address: City: State: Zip Code: Home Phone: Cell Phone: Social Security #: - - Date of Birth: Age: Sex: q M q F Email: Marital Status: qs qm qd
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Patient Information Sheet
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Demographic Information: First Name: Middle: Last name: Birth date: Sex: M F Social Security #: Local Address: City: State: Zip: Secondary Address: (if applicable) Home Phone #: Work Phone#: Cell Phone
record of mental health or substance abuse treatment
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Patient Demographic Information
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:
On the Day Of Your Appointment You Will Need To Bring The Following:
Please complete all patient information forms attached. To better assist you in a timely manner, to guarantee communication with your referring and primary care physicians and to properly care for you,
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PATIENT REGISTRATION
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PATIENT INFORMATION FORM
PATIENT INFORMATION FORM PATIENT DATA Last Name: First Name: Middle Initial: Date of Birth: Social Security [last 4 digits]: Female Male Occupation: Employer: PREFERRED METHOD OF CONTACT Home phone: Preferred
PODIATRIC REGISTRATION AND HISTORY Dr. Peter F. Gregory, D.P.M.
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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?
Rev. Your Address Street or P.O. Box City State Zip. Your Date of Birth / / SS# Phone numbers cell ( ) - home ( ) - work ( ) -
Welcome to Our Office This information will allow us to begin the process that ensures your eye health and vision remain at their best, and that your health and lifestyle needs are met. Thank you for your
If you are prescribed any medications, where would you like the script sent? Pharmacy Name: Pharmacy Phone:
AMELIA A. PARÉ, M.D. PATIENT REGISTRATION Date of visit: PATIENT INFORMATION (PLEASE PRINT) Name: Date of Birth: Age: Male Female Race Social Security #: Marital Status: Single Married Divorced Widowed
S T E P 1 PAT I E N T I N F O R M AT I O N
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Date SSN: DOB: Patient Name. Address
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Patient Registration
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Patient s Full Legal Name: DOB: Sex: M F. SS#: Race: Ethnicity: Marital Status: Patient s Address: City: State: Zip:
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Website: Optometry: Ophthalmology: _ George E. White O.D. FAAO George R. Pronesti M.D.
Print Name: DOB: Emergency Contact: Relationship: Phone #: Person(s) we may share private health information with: Relationship: Primary Care Physician: Pharmacy: ******** ALL PAYMENTS ARE DUE AT TIME
We appreciate your choosing our practice for your eye care health! Please complete and bring the enclosed forms to your appointment:
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Lakeview Eye Care Eye Medicine and Surgery Christine C. Platt, M.D. Chad Lehtonen, O.D. One Lakeview Park Rochester, New York 14613 NOTICE OF PATIENT FINANCIAL RESPONSIBILITY At Lakeview Eyecare, we are
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Skin Problems Unexpected weight Loss/Gain None Explain: None Endocrine: Self Family: Musculoskeletal: Self Family: Thyroid
Demographics Last Name: First Name: Initial: : Guarantor: Address: City: State: Zip: Home #: Work #: Cell #: Email: Communication Preferred: email phone mail Pharmacy of Choice: of Birth: Male Female Ethnicity:
9201 East Mountain View Rd, Suite #125 Scottsdale, AZ Phone:
9201 East Mountain View Rd, Suite #125 Scottsdale, AZ 85258 Phone: 480-661-1600 www.qvisionaz.com MAP & DIRECTIONS We are located in North Scottsdale When taking the Loop 101, exit at Shea Boulevard Travel
BAXLEY EYECARE CENTER
BAXLEY EYECARE CENTER PLEASE PRINT Today s Date Patient s Name Sex Race Birth Date Address City/State Zip Home PH# Work PH# SSN# Employer Person Responsible for Charges Address PH# Insurance Information:
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Patient Information 219 Old Hook Road Westwood, NJ07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com www.2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs.
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Welcome to Kapolei Eye Care
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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 (
Dear Patient, See you soon! The Staff at Eye Health Partners
Dear Patient, Welcome to Eye Health Partners of Middle Tennessee, Inc.! Your doctor has recommended a visit with us and we are looking forward to seeing you. Eye Health Partners is a referral center for
PATIENT INFORMATION FORM RICHARD L. MALINICK, M.D. ORTHOPAEDIC SURGERY 1125 Via Verde, San Dimas, CA
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RETINA ASSOCIATES OF SARASOTA
RETINA ASSOCIATES OF SARASOTA John Niffenegger, MD Elizabeth Richter, MD, PhD Keye Wong, MD 3920 Bee Ridge Road, Bldg. D 1370 E. Venice Ave., Suite 201 1509 53rd Ave. West 3280 Tamiami Trail, Suite 41
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