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1 ALAN R. MALOUF, MD, PA Science Drive, Suite 108 PATIENT REGISTRATION PLEASE PRINT First Name Ml Last Name Address City. State Zip Code Home# Work# Cell # Male/Female Date of Birth Marital Status Employer, Patient (Optional). Emergency Contact. Contact's Home # Name of Person Financially Responsible Address Citv State Zip Code Home# Work# Cell # Relationship to Patient (Child, Spouse, Se If) Referring Physician. Primary Care Physician. Name & Location of Local Pharmacy Name of Prescription Mail-In Service
2 ALAN R. MALOUF, MD, PA Science Drive, Suite 108 PRIMARY INSURANCE: Insurance Company Name_ ID or Policy #_ Group #_ Insurance Company Address. City. State Zip Code. Policy Holders Name. Address (if different from above) Date of Birth Relationship to Patient. SECONDARY INSURANCE: Insurance Company Name ID or Policv # Group # Insurance Company Address City State Zip Code Policv Holders Name Address (if different from above) Date of Birth Relationship to Patient TERTIARY INSURANCE: Insurance Company Name ID or Policv # Group # Insurance Company Address City State Zip Code Policv Holders Name Address (if different from above) Date of Birth Relationship to Patient
3 ALAN R. MALOUF, MD, PA Science Drive, Suite 108 ACKNOWLEDGEMENTS 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's best if you make arrangements not to drive yourself. Adverse reactions, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. I authorize Dr. Alan R. Malouf and/or such assistants as may be designated by him to administer dilating eye drops. I am aware that the eye drops are necessary to diagnose my condition. I certify that the information I entered is accurate and true to the best of my knowledge and is only to be used for treatment, billing & processing of insurance benefits. I will not hold Alan R Malouf, MD, PA responsible for any errors or omissions that I have made in the completion of this form. I further authorize the release of any necessary information, including medical information, to my insurance company in order to determine insurance benefits to which I may be entitled. This authorization may be revoked by me at any time in writing. I authorize Alan R Malouf, MD, PA to release and or send medical information regarding my case to other consulting and/or referring physicians. I understand and agree that regardless of my insurance status, I am responsible for the balance on my account for any professional services rendered. All balances that are past 90 days may be sent to a collection agency. Should your account be sent to a collection agency, you will be financially responsible for all collection fees and legal fees that our office incurs to collect the outstanding delinquent balance. Your account will be processed an additional 35% to cover these costs. Patients without healthcare coverage are expected to pay in full at the time of service. I also understand that I am responsible for obtaining authorization or a referral from my primary care physician for all visits, including follow up appointments and any surgery. I understand that I am responsible for charges incurred for services considered to be non-covered by my insurance company and are payable at the time of service. This may include, but is not limited to, the refraction. An explanation of the refraction is available upon request. I have read and understand the financial policy of the office and agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the office. Effective 10/1/2016. PATIENT/GUARDIAN SIGNATURE DATE.
4 History & Intake Form Past Medical History: (please circle all that apply) Anxiety Arthritis (type: Artificial Joints Asthma Atrial Fibrillation (irregular heartbeat) Bone Marrow Transplantation BPH Cancer (Breast, Colon, Lung, Prostate) : COPD Coronary Artery Disease J Depression Diabetes End Stage Renal Disease GERD Hearing Loss Hepatitis Hypertension HIV/AIDS High Cholesterol Hyperthyroidism Hypothyroidism Leukemia Lupus Lymphoma Pacemaker Radiation Treatment Seizures Stroke Valve Replacement Past Surgical History: (please circle all that apply) Appendix Removed Bladder Removed Mastectomy (Right, Left, Bilateral) Lumpectomy (Right, Left, Bilateral) Breast Biopsy (Right, Left, Bilateral) Colectomy: Colon Cancer Resection Colectomy: Diverticulitis Colectomy: IBD Gallbladder Removed Coronary Artery Bypass Coronary Angioplasty (PTCA) Mechanical Valve Replacement Biological Valve Replacement Heart Transplant Joint Replacement-Knee (Right, Left, Bilateral) Joint Replacement-Hip (Right, Left, Bilateral) Joint Replacement within last 2 years Kidney Biopsy Kidney Stone Removal Kidney Transplant Ovaries Removed: Endometriosis Ovaries Removed: Cyst Ovaries Removed: Ovarian Cancer Prostate Removed: Prostate Cancer Prostate Biopsy TURP Skin Biopsy Basal Cell Cancer Surgery Squamous Cell Carcinoma Surgery Melanoma Surgery Spleen Removed Testicles Removed (Left, Right, Bilateral) Tonsillectomy Hysterectomy: Fibroids Hysterectomy: Uterine Cancer Hysterectomy: Cervical Cancer Hysterectomy: Endometriosis Ocular History: (please circle all that apply) Allergic Conjunctivitis Blepharitis Cataract (Left Eye, Right Eye) Corneal Dystrophy (Left Eye, Right Eye) Diabetic Retinopathy (Left Eye, Right Eye) Dry Eyes Glaucoma (Left Eye, Right Eye) Keratoconus (Left Eye, Right Eye) Macular Degeneration (Left Eye, Right Eye) Macular Pucker (Left Eye, Right Eye) Narrow Angles (Left Eye, Right Eye) Ocular Hypertension (Left Eye, Right Eye) Ophthalmic Migraine Pseudoexfoliation Retinal Tear (Left Eye, Right Eye) Strabismus PVD (vitreous detachment) (Left Eye, Right Eye) Vitreous Floaters (Left Eye, Right Eye) _
5 Do you wear Contact Lenses? Yes/No If yes, please list brand name:. Ocular Surgery: (please circle all that apply) Blepharoplasty (Left Eye, Right Eye) Cataract Surgery (Left Eye, Right Eye) Corneal Transplant (Left Eye, Right Eye) DSAEK (Left Eye, Right Eye) Eye Muscle Surgery Intravitreal Injections (Left Eye, Right Eye) Laser for Glaucoma (Left Eye, Right Eye) Laser for Diabetes (Left Eye, Right Eye) LASIK (Left Eye, Right Eye) PRK (Left Eye, Right Eye) Ptosis Repair (Left Eye, Right Eye) Punctal Plugs (Left Eye, Right Eye) Strabismus Surgery Retinal Laser (Left Eye, Right Eye) Trabeculectomy (Left Eye, Right Eye) Tube Shunt (Left Eye, Right Eye) Vitrectomy (Left Eye, Right Eye) YAG Capsulotomy (Left Eye, Right Eye) Medications: (please list all current medications) Allergies: (please list all allergies) Social History: (please circle all that apply) Cigarette Smoking: Never smoked Quit: former smoker Smokes less than daily Smokes daily Alcohol Use: Alcohol: none Alcohol: less than 1 drink a day Alcohol: 1-2 drinks a day Alcohol: 3 or more drinks a day Family History: (please circle all that apply) Blindness Cancer Cataracts CVA (stroke) Diabetes Glaucoma Heart Disease Macular Degeneration Migraine Retinal Detachment Strabismus FORFEMALES: Is there a chance you might be pregnant? Yes/No
6 ALAN R. MALOUF, MD, PA Science Drive, Suite 108 FINANCIAL POLICY & NON-MEDICAL FEES We are happy to accommodate our patients' needs for various administrative services that are not covered by insurance. These may include, but are not limited to, the following: REQUEST FOR MEDICAL RECORDS Maryland law allows physicians to charge patients (or the patient's "personal representative") a fee for copying medical records. The charges may be adjusted annually accordingto changes in the law. Effective immediately, the fee remains as stated below: Afee for copying not to exceed.76 cents for each page of the medical record, and The actual cost of postage and handling. A Preparation Fee of $22.88 may apply. Your signed authorization is required for each release to yourself or others. The office will provide a Records Release form. However, you may also use any form or letter which contains the same information requested in our form. Your non-urgent request for copies of your medical records will be processed in 3-5 business days. Fees for processing your requests will be billed to your account and are due immediately prior to the release of records. Your urgent request for records sent to another provider will be faxed as soon as possible at no charge for 5 or fewer pages. We will work with you to minimize your cost for records. There is no charge for letters sent back to your primary care physician or sent to a referring physician. This is part of our coordination of your care. OTHER FEES NOT COVERED BY INSURANCE Single/Multi Page Forms Returned Check Fee $25.00 These forms will be completed within 1 week $35.00 Payable immediately + original amount due Refraction Fee $40.00 Some medical insurance plans will coverthis. If your plan does not cover the refraction, the fee is due at the time of service. Medicare does NOT cover the refraction. We will provide a detailed receipt with necessary information which you may choose to submit to your vision plan since we do not participate with these plans. MVA Forms No Charge. (At this time the office is not charging a fee.) You may bring your MVA form to your scheduled appointment, and it will be completed at that time. Ifyou bring/mail your MVA form to us, the doctor will usually complete it the same day. However, it could take 3-5 days to complete. You may pick up your form or have it mailed to your home. We cannot mail your form directly to the MVA.
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Date. Cell Phone: ( )
Date / / Name: Date of Birth: / / AGE: Last First MI Home Address: City: State: Zip: 2 nd Home Address: City: State: Zip: Email Address: Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Is it okay to leave
Illinois Dermatology Institute
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Metrolina Dermatology and Skin Surgery Specialists Park Road, Suite 100 Charlotte, NC
Metrolina Dermatology and Skin Surgery Specialists 10502 Park Road, Suite 100 Charlotte, NC 28210 www.metrolinadermatology.com Dear Patient, We thank you for choosing Metrolina Dermatology and Skin Surgery
(Last) (First) (Middle) Home Phone: Work: Cell: (Include Extension, if applicable) (OK to Text )
JEFFREY S. GREENWALD, M.D. MICHAEL S. HENNER, M.D. ROBERT W. DEMETRIUS, M.D. KEMKA S. OGBURIA, M.D. DINAH M. WARNER, M.D. KATHLEEN B. ZENDELL, M.D. STEVEN M. PRICE, M.D. EDWARD J. POSNAK, M.D. ASHLEY R.
Minor Patient Information
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Address: Primary Insurance Co. Name: Policy Holder:
Today s Date: / / PATIENT INFORMATION Name: Last First M.I. Mailing Address: Street City State Zip Code Home Phone: Work Phone: Cell Phone: OK to leave message: Yes No OK to leave message: Yes No OK to
Soderma Dermatology. General, Surgical & Cosmetic
S D General, Surgical & Cosmetic Welcome to Soderma, General, Surgical & Cosmetic Dermatology. We are a comprehensive dermatology practice, providing a full range of medical, surgical and cosmetic dermatologic
PATIENT INFORMATION. Patient s last name: First: Middle: Marital status:
Today s Date: PATIENT INFORMATION Patient s last name: First: Middle: Marital status: Is this your legal name? If not, what is your legal name? Former name: Birth date: Age: Sex: Yes No M F Address: [Address/
Burnet Eye Care & Llano Eye Care P.O. Box 426 Burnet, TX phone 102 E Young St Llano, TX phone
Burnet Eye Care & Llano Eye Care P.O. Box 426 Burnet, TX 78611 512-756-2131 phone 102 E Young St Llano, TX 78643 325-247-2020 phone PATIENT REGISTRATION Patient s Name Today's Date Mailing Address City
EYE SPECIALISTS OF GEORGIA PLEASE ANSWER ALL QUESTIONS
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History and Intake Form. Date of Birth:
History and Intake Form Name: Date of Birth: Name I prefer to be called: Past Medical History: (please check all that apply) Anxiety Arthritis Asthma Atrial fibrillation (irregular heartbeat) BPH Bone
If have a specialist co-pay, we will collect that at time of service.
Metrolina Dermatology and Skin Surgery Specialists 10502 Park Road, Suite 100 Charlotte, NC 28210 www.metrolinadermatology.com Phone: 980-299-3926 Dear Patient, We thank you for choosing Metrolina Dermatology
Stark County Surgeons, Inc Patient Information. Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - -
Today s Date: / / Patient Information Patient Name: Address: City: State: Zip: Date of Birth: / / Social Security Number: - - Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Other phone: ( ) - E-Mail
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
PATIENT INFORMATION PRIMARY INSURANCE INFORMATION
1001 Medical Plaza Dr. The Woodlands, TX 77380 www.woodlandsretina.com Tel: 281-367-9700 Fax: 281-367-9701 PATIENT INFORMATION Patient s Legal Name: Date of Today s Visit: Social Security # Date of Birth:
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
BIRCH BAY DERMATOLOGY
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We look forward to meeting you soon!
Dear New Client: We are pleased to welcome you to our practice! Thank you for allowing us to serve your health care needs. We are enclosing with this letter our new patient information forms. Please complete
NOTICE ABOUT REFRACTION
NOTICE ABOUT REFRACTION We have you scheduled for a complete eye exam or surgical consultation today. All surgical consultations require a refraction in order to determine which vision correction procedure
Patient Registration Form
I Patient Registration Form Please Print Clearly and Fill in All the Blanks PATIENT INFORMATION First Name: Middle Initial: Last Name: DOB: Age Address: Apt #: City: State: Zip: SSN: Driver License Number: