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1 PATIENT INFORMATION FORMS (JUNE 2016) PATIENT INFORMATION: (PLEASE PRINT) WHO SHOULD WE THANK FOR REFERRING YOU TO OUR OFFICE? PATIENT FULL NAME: MARITAL STATUS: GENDER: SINGLE DIVORCED MALE MARRIED WIDOWED FEMALE CURRENT AGE ADDRESS: CITY: STATE: ZIP: EMPLOYED BY: OCCUPATION: ********************* PREFERRED COMMUNICATION: Please check at least one option May we leave a message? (Name and number only) HOME YES NO YES NO PHONE: Leave a message DAYTIME PHONE: Leave a message CELL PHONE: Leave a message Texting Yes No ****I authorize the use of my address for PATIENT COMMUNICATION only. I AUTHORIZE THE RELEASE OF MY MEDICAL AND/OR FINANCIAL INFORMATION TO THE FOLLOWING INDIVIDUAL(S): I.E. SPOUSE, PARENTS, KIDS) Name(s) and relationship to patient PARENTS, SPOUSE, CHILDREN OR ENTER **** WHOSE NAME IS THE INSURANCE UNDER? RELATIONSHIP TO PATIENT? *FULL NAME: SELF SPOUSE PARENT GUARDIAN EMPLOYER: SAME BILLING ADDRESS AS ABOVE YES NO If different from patient: Insured s Address: PRIMARY MEDICAL INSURANCE CARRIER: IDENTIFICATION# and GROUP#: SECONDARY INSURANCE CARRIER: IDENTIFICATION # AND PLAN OR GROUP# VISION INSURANCE NAME AND IDENTIFICATION #: ***MUST BE COMPLETED IN ORDER TO FILE INSURANCE IF NOT COMPLETE WE ARE UNABLE TO FILE YOUR INSURANCE!! This information will be shredded after being entered in our computer system. PATIENT S DATE OF BIRTH: PATIENT S SS#: Patient s DRIVER S LICENSE#: EXPIRES: STATE: EMPLOYEE/PRIMARY INSURED S DATE OF BIRTH: SS#: 1
2 HEALTH HISTORY PLEASE FILL OUT COMPLETELY, THANK YOU! PATIENT NAME: MEDICAL HISTORY: HAVE YOU EVER HAD (PAST MEDICAL CONDITIONS) ANY OF THESE CONDITIONS? Diabetes Heart Problems Thyroid Rheumatoid Cholesterol Stroke Asthma Alzheimer s Hypertension Parkinson s Lupus COLD SORES/FEVER BLISTERS/Herpes Cancer EYE HISTORY: HAVE YOU EVER HAD ANY OF THESE EYE CONDITIONS? Glaucoma Cataracts Floaters Macular Degeneration Flashes Other: SURGICAL HISTORY: CATARACT LASIK APPENDECTOMY HERNIA AFTER CATARACT LASER PRK BREAST HYSTERECTOMY EYE MUSCLE RK GALLBLADDER KNEE RETINAL HEART PROSTATE PLEASE LIST ANY OTHER SURGICAL PROCEDURES: ** ALLERGIES: List all medications you are allergic to (i.e. Penicillin) MEDICATIONS (Prescription and Over the Counter) and reason for the medication AND DIRECTIONS (i.e. Lipitor Cholesterol 20MG DAILY) INCLUDE ANY EYE DROPS, VITAMINS OR SUPPLEMENTS YOU ARE USING. Medication Strength Dosage Medical Condition FAMILY MEDICAL HISTORY: Does anyone in your family have any of the following medical conditions: Family Members Diabetes Glaucoma Macular Degeneration Hypertension Mother Father Sister Brother Aunt/Uncle Mat. Grandmother Mat. Grandfather Pat. Grandmother Pat. Grandfather 2
3 REVIEW OF SYSTEMS: Please indicate your present/current medical conditions below. Cardiovascular Genitourinary Musculoskeletal High Blood Pressure Menopause Rheumatoid Arthritis Stroke Prostate Disorder Arthritis Cholesterol Hematologic/Lymphatic Osteoporosis Heart Disease Blood Clots Neurological Constitutional Leg/Muscle Cramps Migraines Weight changes Anemia Headaches Ears, Nose, Throat Immunologic Psychiatric Hearing Loss Sjogren s Syndrome Alzheimer s Sinus problems Sarcoidosis Memory Loss Endocrine Shingles Respiratory Diabetes Cold Sores/Fever Blisters Asthma Thyroid Disorder Integumentary/Skin COPD Renal Disease Lupus Emphysema Gastrointestinal Raynaud s Disease Cancer Hepatitis Rosacea Acid Reflux * PATIENT SOCIAL HISTORY: Use of Tobacco No Yes Use of Alcohol No Yes Additional Space for Medications: Medication Strength Dosage Medical Condition Other conditions not listed above: To the best of my knowledge, the questions on this form have been answered completely and accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Dr. Goffman of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need. Signature of Patient or Responsible Party Date Printed Patient Name 3
4 Dear Patient: ATTENTION ALL PATIENTS WHO ARE COVERED BY INSURANCE/MEDICARE We are committed to providing you with the best possible care. If you have medical or vision insurance, we are committed to helping you receive your maximum allowable benefits. When verifying benefits through our online clearinghouses, the information we receive from your insurance company is sometimes not always accurate. We encourage our patients to be familiar with their own insurance benefits. Patients are responsible for payment at the time of service. An estimate of your out-of-pocket expenses will be given to your prior to your appointment. You are responsible for any unmet deductible, coinsurance or copays and any non-covered services at the time services are rendered. In order for us to file your claim in a timely manner a copy of your Medicare and/or insurance card will be needed as well as your referral from your primary care physician, if required by your insurance carrier. For patients with secondary insurances we only file to your primary insurance carrier, you will need to file for reimbursement to your secondary insurance. Medicare patients, your secondary will be accepted only if Medicare forwards the claim to your secondary policy directly. For our Out-of Network patients, you will be given an itemized receipt to file with your insurance company. Normal processing time takes 4-6 weeks for most insurance companies. We will make every attempt to work with your insurance company should they require additional information to process your claim. However, if your insurance company fails to make a payment within a reasonable length of time, issues a denial notice, and or goes into receivership, the balance will then be billed to you directly. A reasonable length of time is considered to approximately 5-6 weeks. We must emphasize that, as a medical care provider, my relationship is with you, not your insurance company. While filing of insurance is a courtesy we extend to my patients, all charges are your responsibility from the date the services are rendered. I agree to assume any financial obligation involved in the full payment of services, which include all outstanding balances not covered by Medicare and/or my insurance company. I authorize any holder of medical information to release to the Social Security Administration or its intermediaries or carriers, or to the billing agents of the insurance companies listed on my patient information record, or to my employer or worker s compensation carrier. Any information needed for this insurance or Medicare claim to be processed. DR. GOFFMAN RECOMMENDS CERTAIN SCREENING DIAGNOSTIC TESTS WHICH ALLOW HIM TO PERFORM A MORE COMPREHENSIVE AND THOROUGH EXAMINATION. THESE TESTS INCLUDE: TOPOGRAPHY, RETINAL PHOTOS AND OPTICAL COHERENCE TOMOGRAPHY OCT REFRACTIONS MAY OR MAY NOT BE COVERED BY YOUR MEDICAL/VISION PLAN. CONTACT LENS SERVICES, CONTACT LENSES, GLASSES, LASER VISION CORRECTION AND THE PREMIUM IMPLANTS FOR CATARACT SURGERY ARE NOT COVERED BY YOUR MEDICAL OR VISION PLANS. I HAVE RECEIVED THE NOTICE OF PRIVACY PRACTICES AND I HAVE BEEN PROVIDED AN OPPORTUNITY TO REVIEW IT. I authorize the release of any medical or other information necessary to process any insurance claim. I also authorize payment of medical benefits to Joel H. Goffman, M.D., P.A. I UNDERSTAND THAT MY INSURANCE BENEFITS MAY OR MAY NOT COVER ANY OR ALL SERVICES. I understand that any cancellation or NO-Show appointment given without 48-hour notice will result in a $25.00 rescheduling fee. X PATIENT OR RESPONSIBLE PARTY SIGNATURE X DATE 4
5 Joel H. Goffman, M.D Katy Frwy, #101 Houston, Texas Estimated Patient Out-of-Pocket Charges Medical and Vision insurance does not cover all services. Dr. Goffman recommends these diagnostic screening tests for an accurate and complete examination. Refractions are not always covered by insurance. Contact lenses and contact lens services are not covered by your insurance. These services may include the following: Routine Vision UHC Vision/Spectera/Optum Vision Patients under 35 $25 Topography Copay or Deductible +25+(contact lens service Patients $66 Topography, Fundus Photos Copay or Deductible +66+(contact lens service Patients over 50 $86 Topography, Fundus Photos, OCT Copay or Deductible +86+(contact lens service Medical Insurance (Refractions might be covered depending on your plan) Patients under 35 $75 Refraction, Topography Copay or Deductible +75+(contact lens service Patients $116 Refraction, Topography, Fundus Photos Copay or Deductible +116+(contact lens service Patients over 50 $136 Refraction, Topography, Fundus Photos, OCT Copay or Deductible +136+(contact lens service Contact Lens Services Contact Lens Fit Under 21 $175, Standard Fit $225, Monovision $275 Based on the type of contact lenses the doctor recommends Contact Lens Evaluation Update contact lens prescription for existing $95-$150 or Modification contact lens wearer Medicare Patients Glasses wearers Refraction $136 Contact lens wearers Refraction +Contact Lens Evaluation $231 Exam fees Cash Price (no Insurance) New Patient non contact lens wearer Established Patients non contact lens wearer Patients under 35 $226 $181 Patients $252 $222 Patients over 50 $252 $242 New Patient contact lens wearer Established Patient contact lens wearer Patients under 35 $321 $276 Patients $347 $317 Patients over 50 $347 $337 OTHER SERVICES Corneal Thickness $25 Post laser surgery patients PD Measurement $25 Glasses measurements to order glasses online Baseline OCT < 50 $35 This is a onetime measurement for a base line Macular Density $35 Measures the macular pigment layer The above pricing is an estimate. If additional testing is required by Dr. Goffman it will be added to your services. I have received, read, and understand this notice. If you have any questions, please ask the staff to clarify any charges prior to services being rendered. Thank you! Signature: Date: 5
6 JOEL H. GOFFMAN, M.D., P.A KATY FREEWAY, SUITE 101 HOUSTON, TX (713) Fax (713) INFORMATION REGARDING DILATING EYE DROPS Dilation involves instilling eye drops for the purpose of enlarging the pupils of the eyes. This allows a better examination of the eyes internal structures. Thorough examination of these structures is necessary to rule out various eye disease or pathology (Macula, Retina, Optic Nerve or Retinal issues). Dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome and your up-close vision will be blurry. It is not possible for your ophthalmologist to predict how much your vision will be affected. I hereby authorize Dr. Goffman and/or such assistants as may be designated by him to administer dilating eye drops. The eye drops are necessary to diagnose my condition. Print Patient Name Date Patient Signature (or person authorized to sign for patient) DILATION REFUSAL WAIVER PATIENT MAY REFUSE In this office, patients reserve the right to refuse any test or diagnostic procedure, despite our recommendations. If a patient refuses, however, he or she assumes ALL of the risk for possibly not being able to detect and diagnose, and thereby treat in a timely manner, any potentially serious eye conditions. We request a signed waiver in these cases. PATIENT MAY RESCHEDULE Some patients prefer to reschedule their dilated retinal exam for a different day and time to minimize visual sideeffects upon return to work or school. We will be happy to offer a second appointment for this purpose. For Extended Ophthalmoscopy, We currently charge $35.00, which will be assessed at the second appointment. There is absolutely NO additional charge if we complete the dilated retinal exam during your routine eye examination. (To be signed ONLY if you are refusing dilation) I, under my own will and judgment, refuse to have my eyes dilated. As a direct consequence, I understand that Dr. Goffman may not be able to detect cases in which the retina physically compromised. Accordingly, the process of early detection and diagnosis of certain eye conditions may be hindered and timely referral to a specialist and effective treatment may not be possible. I accept ANY and ALL risk of the possibility of not detecting these eye conditions without a papillary dilation, and I understand these conditions may result in a loss of vision. Name: Date: Signature: 6
MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED GENDER: MALE FEMALE
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