I Federal Law requires us to ask race: Hispanic Non-Hispanic

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1 Today's Date <II>< 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 Phone Is Patient? Address Single Married Widowed Divorced Full-time Student Part-time Student I Federal Law requires us to ask race: Hispanic Non-Hispanic Cell Number Social Security Number Emergency Contact (does not live with you) Relationship Phone # Referring Physician Family Physician Employer's Name Street Address Business Phone City State Zip Is patient's condition related to? A. Employment B. Auto Accident C. Other Accident If yes, explain Spouse Name (last, first, middle) Date of Birth Social Security # Date of accident Spouse's Employer Business Phone If patient is a child, please complete: Father's Name Street Address Home Phone SS # DOB City State Zip Work Phone Mother's Name Street Address Home Phone SS # DOB City State Zip Work Phone Complete the Insurance information below Insurance Company Contract Number Group lnsured's Name lnsured's SS# Relationship to Paitent Does coverage include vision? Insurance Company Contract Number Group lnsured's Name lnsured's SS# Relationship to Patient Does coverage include vision? * Most health insurances do NOT cover routine vision care. Vision insurance covers only routine care. If you have any questions as to whether your insurance will cover your visit, please ask.

2 Patient Billing/Payment Authorization Each patient is responsible for obtaining a referral if one is required by your insurance carrier. It is the patient's responsibility to ensure that Patricia M. McCoy, M.D. is a participating provider with their insurance carrier. If Patricia M. McCoy, M.D. is a participating provider with the patient's insurance carrier, we will file your claim for your office visit or surgery and allow 45 days for payment in full. If you do not have insurance, do not have a referral for the service date or we are not a participating provider with your insurance carrier, payment is expected at the time services are rendered. Co-payments and non-covered fees, such as refraction fees, are the responsibility of the patient and are due at the time of service. A refraction is a reading to determine your best corrected vision. Insurance does not usually cover the cost of refractions. It is the policy of Patricia M. McCoy, M.D. to collect all payments in full at the time of service. If your visit is a result of an injury or accident involving a lawsuit, (excluding workers comp), we will gladly provide receipts for all services rendered for your reimbursement. Extended Patient Signature Authorization Authorization for Patricia M. McCoy, M.D. I request that payment of authorization Medicare benefits be made either to me or on my behalf to Patricia M. McCoy, M.D. for any services or items furnished to me by the physician or supplier. I authorize any holder of medical information about me to release to the Health Care Financing Administration or other insurance company and its agents any information needed to determine these benefits or the benefits payable for related services. I request that payment of (patients insurance company/companies on file) benefits be made directly to Patricia M. McCoy,M.D. By signing below, I understand that routine vision care, refraction fees, diagnostic testing, and co-pays may not be covered by my insurance carrier and I am responsible for these services at the time they are rendered. * Signature of beneficiary or person signing for beneficiary Date signed Parental Consent for the Treatment of a Minor Please be advised that anyone seeking medical treatment or routine eye care under the age of 19 is required to have parental consent. This consent must be given by a parent or legal guardian. Your signature below gives us consent to provide the necessary medical care and/or vision care deemed necessary by the physician providing the care. By signing below you additionally accept financial responsibility for the treatment of the dependant child. All co-pays and/or fees are the responsibility of the guarantor presenting the minor for services/treatment regardless of any legal and/ or verbal agreement between the parents. Patient's Name Guarantor's Signature Guarantor's DOB M/F Relationship of guarantor Guarantor's Social Security# Today's Date Sex of the guarantor Receipt of Notice of Privacy Practices Written Acknowledgement Form I,, have received a copy of the Notice of Privacy Practices. Signature of Patient: Signature of Guardian: Date: Date:

3 I have reviewed both sides of this questionnaire with patient Date MD Initials Date MD Initials Date MD Initials YOUR PHYSICIAN WOULD LIKE TO PROVIDE YOU WITH THE HIGHEST QUALITY CARE POSSIBLE. TO ASSIST HIM/HER, WE ASK THAT YOU COM- - PLETE THE FOLLOWING HEALTH HISTORY SO THAT YOUR OVERALL HEALTH MAY BE ASSESSED AND INCORPORATED INTO YOUR EYE CARE. MEDICAL HISTORY QUESTIONNAIRE Sex: M [ ] F [ ] Age: Today's Date: Current EYE Problem: Drug Allergies: -- Are You On Blood Thinners? Yes [ j No [] If Yes, Which? --- Who yourfami Physician? -- YOUR MEDICATIONS List All Medications you take, including Over-The-Counter medicines and vitamins/supplements: MEDICAL HISTORY Do You Have a Problem With: Yes No If yes, please explain Yes No If yes, please explain Skin Disease Head (Headaches) Ear/Noseffhroat/Mouth Lungs/Breathing(TB!Astbma} _ Heart Disease High Blood Pressure Stomach/Intestines Genitals/Kidney/Bladder Arthritis Bones/Joints/Muscles Neuro/Stroke Lymph Nodes/Swelling Other Problems: Please List: Diabetes/Sugar Cancer Cholesterol Thyroid Allergies (Environmental) _ Allergies (Food) Kidney Stones Urinary Bleeding Disorder Blood (HIV/Hepatitis) Infectious Disease Psychiatric Treatmen t OPERATIONS List any previous operations, general and eye related Date Complications or Difficulties I

4 Describe: Family History and Visual Inventory Your Eye History... Right Left Right Left Amblyopia (lazy eye) Muscle Disorder Cataract Lacrimal Obstruction Corneal Transplant Macular Degeneration Diabetic Retinopathy Retinal Detachment Glaucoma Iritis Eye Injury, please provide date --- List all eye medications you use (including over-the-counter meds): Have you ever worn glasses or contact lenses? Yes [] No [] How old is your prescription? _ Are you happy with your current glasses? Yes [] No [] or Do you need an eye glass exam? Yes [] No [] Your Family History.. Do/did any family members have? Yes No Father Mother Sibling Other, explain Blindness Cataract Glaucoma Macular Degeneration Strabismus (crossed eye) Diabetes Heart Disease High Blood Pressure Thyroid Disease Social History. Yes No Yes No Marital Status: S M W D Live alone? Nursing Home Do you? Smoke? Chew Tobacco Use Drugs? Drink Alcohol

5 100A Providence Main Suite 1E, Huntsville, AL (256) Fax (256) <I>< McCoy VISION Thank you for choosing Dr. McCoy to handle your eye care needs. We have your appointment with our office scheduled on our (Huntsville or Scottsboro) office. Our Huntsville office is conveniently located on the corner of University Drive and Providence at in Main. The entrance to our office is on the back east side of the building, above the CVS. If you have any questions about our new office location or your care with Dr. McCoy, please talk to one of our staff members about it. We will be happy to take the time to be sure your questions are answered. You can reach our office at Please bring the following to your appointment: Your completed paperwork Current medications Your insurance cards Your copay or deductible and $25 refraction fee if being refracted (needing a glasses prescription), this is not included in the exam fee and is not covered by most insurance plans Your current prescription for glasses or contact lens During your exam your pupils may be dilated and dilating drops cause a variable amount of blurry vision for an unpredictable length of time. We cannot tell you how much your vision will be affected and for exactly how long. Because driving safely may not be possible after having your eyes dilated, you should make arrangements to have someone drive you after your appointment. Dr. McCoy is a medical physician and sees patients for both medical and vision exams. Unless you have a known condition, we cannot determine until after you have been seen by the doctor if you have a medical diagnosis or a (refractive) vision diagnosis, we request that you call your insurance company to clarify any questions you may have about your medical and vision coverage. If your insurance requires a referral please obtain your referral from your primary care doctor prior to your visit. Please visit our website Satellite location: 323 Parks Avenue,.., Scottsboro, AL mccoyvision.org