PATIENT INFORMATION FORM

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Michael Alvin Hensley
5 years ago
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1 PATIENT INFORMATION FORM PATIENT INFORMATION Patient Name: Last First MI Home Phone # Cell Phone # ( ) ( ) of Birth Social Security # Sex Marital Status o Male o Single o Married o Divorced o Female o Separated o Widow Address City State Zip Code Race: o African American o Asian o Indian o Hispanic o Caucasian o Native American o Other Mailing Address (if different from home address) City State Zip Code May we contact you by ? o Yes o No Address: Employer s Name Address Work Phone # Occupation Have you or your spouse retired from a military career? o Yes o No SPOUSE INFORMATION IF APPLICABLE / PARENT INFORMATION Spouse / Parent / Guardian Name Home Address Relationship to Patient o Spouse o Parent o Guardian o Other Home Phone # Social Security # of Birth Employer s Name Address Work Phone # CARRIER OF INSURANCE INFORMATION Patient s Primary Insurance ID # Policy Holder s Name Social Security # of Birth Relationship Patient s Secondary Insurance ID # Policy Holder s Name Social Security # of Birth Relationship GENERAL INFORMATION Emergency Contact (other than spouse) Referred by: Please be specific Name Relationship Dr. Phone # Name of family member to release health information: Other HIPAA DISCLOSURE & INSURANCE AUTHORIZATION/ASSIGNMENT AGREEMENT I hereby authorize this office disclosure of health information and/or to apply for benefits on my behalf for covered services rendered. I request payment from my insurance company to be made to the above named provider. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, to other treating physicians and to my insurance company in order to determine Insurance benefits to which I may be entitled. Either myself or my insurance company at any time may revoke this authorization in writing. address used for information only not shared with others. As of this office is complaint with the HIPAA OMNIBUS Rule. By signing below, I acknowledge that I have read and understand this authorization form. Signature of Patient or Patient s Representative.

2 HEALTH HISTORY FORM : Name: Primary Care Doctor s Name: Telephone # Please review and mark any problems you may have now, or have had in the past 12 months: Neurological Endocrine Psychiatric Genitourinary General Fainting/Blackouts Diabetes Type Emotional Disorder Prostate Problems Cancer Type Seizure/Epilepsy Thyroid Problems ADD/ADHD Uterine/Ovarian Problems Chemo/ History of Stroke Graves Disease Anxiety Bladder Problems Radiation/ Migraine Headaches Childhood Illness Depression Kidney Problems STD/Type Paralysis Chicken Pox Cardiovascular Gastrointestinal Steroid Use for: Vertigo Mumps High Blood Pressure Hiatal Hernia Lupus Bell s Palsy Measles Heart Disease/Murmur Frequent Heartburn Immune Disease Alzheimer s Diptheria History of Heart Attack Ulcers Herpes Simplex Downs Syndrome Whooping Cough Chest Pain Hepatitis/Type Herpes Zoster/Shingles Dementia Scarlet Fever Angina Liver Problems Sarcodosis Meningitis: Bacterial or Viral Polio Irregular Heartbeats Irritable Bowel Syndrome Ocular Parkinson s Respiratory Rheumatic Fever GERD Macular Degeneration Hemato/Lymphatic Chronic Cough Pacemaker/Defibrillator Musculoskeletal Glaucoma Anemia Asthma High/Low Cholesterol Back Injury Floaters Bleeding Tendency Emphysema Ear/Nose/Mouth/Throat Neck Injury Dry Eye Hemophilia Tuberculosis Sinus Problems Herniated Disc Macular Hole Easy Bruising Blood Transfusion Jaundice Sickle Cell Anemia Pneumonia Sleep Apnea Bronchitis Breathing Problems SARS COPD Loose/Chipped Teeth False Teeth/Caps Hoarseness Difficulty Opening Mouth Hard of Hearing Tinnitus Rheumatoid Arthritis Osteoporosis Multiple Sclerosis Fibromyalgia Muscle Pain or Cramps Lyme Disease Retinal Tear or Detachment Amblyopia/Lazy Eye Other/Type List all (eye) surgeries Family History (please include which relative was diagnosed): Glaucoma Diabetes Macular Degeneration Other List all Previous Surgeries: Please turn over and complete the back of this form.

3 Have you ever experienced any of the following during or after anesthesia? No / Yes Check which apply if yes. High Temperature Jaundice Headache Allergic Reaction Delayed Awakening Excessive Bleeding Hoarseness/Sore Throat Prolonged Weakness Muscle Soreness Nausea and Vomiting Difficulty with Breathing Tube Other Tobacco Use: No / Former Smoker / Yes - Amount / How many packs per day? For how many years? Alcohol Use: No / Yes - Amount Street/Recreational Drugs: No / Yes - Type? Have you ever been tested for AIDS or HIV? Have you ever been diagnosed with MRSA? No/Yes - Results: No / Yes Could you be Pregnant? No / Yes - Start date of last Menstrual Period? / / Height Weight Are you currently taking Flomax? No / Yes Have you ever taken Flomax? No / Yes Are you allergic to Latex? No / Yes Please list all allergies to medications including reaction: Medication Name Reaction Medication Name Reaction Please list all current medications below: Medication Name Dosage How Often Medication Name Dosage How Often I have fully reviewed this questionnaire and answered all questions truthfully and to the best of my knowledge. I am aware that my answers could effect my health care, or that of patient for whom I am responsible. Patient or Responsible Party Signature:

4 SIEHT POLICIES AND AUTHORIZATIONS SIEHT: A Falkenberg Eye & Laser Center is dedicated to providing the best possible care and service to you, and regards the complete understanding of this policy as an essential element of your care and treatment. Please carefully read all SIEHT policies, as some may directly impact your next appointment at SIEHT. After review our policies please sign this form acknowledging that you understand these policies and authorizations. Financial Policy: As a courtesy, we will bill your insurance. Your insurance is a contract between you and your insurance carrier. You are responsible for knowing your insurance plan benefits, and obtaining any referral or precertification (if applicable) before services are rendered. You are required to provide all current information about your insurance to ensure it is up to date allowing proper filing of your claims. Self-Pay Patients who are not insured are required to pay in full at the time of service. The cost for any date of service is not complete until the finished documentation of that visit is reviewed by our billing department. Any price quoted to you, before your visit or at the checkout desk after your visit is an estimate. We accept Cash, Check, and Money Order as well as debit/credit MasterCard, Discover, Visa and American Express. Returned Checks will incur a $50.00 service charge. You will be asked to bring certified funds or a money order to cover the amount of the check plus the service charge prior to receiving services from our staff or physicians. If you have any questions, please ask to speak with our Billing Department at ext Refraction Fee: Eye Examinations have two portions, the eye exam and the refraction. The refraction is the measurement taken to determine if there is a need for glasses and if so, your glasses prescription. Refractions may be done for routine eye exams or medical exams. Refractions have always been a NON-COVERED service under the MEDICARE program. OTHER INSURANCE and secondary plans may vary depending on your individual benefit coverage. Unless you have routine vision benefit coverage on your insurance, they will NOT cover the cost of the refraction. This fee is due at time of service. If you have a refraction completed, the $40.00 refraction fee will be collected the day of your appointment at the check-out counter. Missed Appointment Policy: Patients or their legal guardians are expected to call the office at least 24 hours in advance if they are unable to keep their scheduled appointments. As a courtesy, our staff will call you 2 business days in advance to remind you of your appointment. It is your responsibility to provide us with a working telephone number. The Practice reserves the right to charge a $35.00 missed appointment or no show fee. If you have missed a total of 3 appointments we reserve the right to deny another appointment to you. This charge is not covered by any insurance plan; therefore, you will be personally responsible for this fee. Form Fees: Completing insurance forms, copying of medical records, filling out disability and DMV etc. require time away from patient care for our staff and Doctors. There will be a $10.00 Administrative fee for filling out forms or copying medical records. There will also be a charge of $.50 per page for the first 50 pages and $.25 per page thereafter. You will be required to sign a records release prior to receiving your medical record. The practice requires 2 business days to gather and prepare Medical Records or filling out any forms to leave the office. I acknowledge that I have read and understand these policies and authorizations. PATIENT/RESPONSIBLE PARTY SIGNATURE

5 Notice of Privacy Practices Acknowledgment I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from designated third-party payers. Conduct normal health care operations such as quality assessments or evaluations and physician certifications. I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information (available in the office in print form and online at I have reviewed such Notice of Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices prior to signing this consent, and acknowledge that I have studied the Privacy Practices. I understand that this organization has the right to change its Notice of Privacy Practices from time to time, and that I may contact this organization at any time at the address above to obtain a current copy of the Notices of Privacy Practices. I understand that I may request in writing that this organization restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand the organization is not required to agree to my requested restrictions, but if the organization does agree, then it is bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that the organization has taken action relying on this consent. Patient Name of Birth Signature

Patient Information. Patient Information Patient s Name: Date of Birth: / / Last First M

Patient Information. Patient Information Patient s Name: Date of Birth: / / Last First M Patient Information Patient Information Patient s Name: Date of Birth: / / Last First M Mailing Address: Street City State Zip Social Security Number: - - Single Married Divorced Widowed Separated Home