Demographic Information Form

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Emily Atkins
5 years ago
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Demographic Information Form Today s Date: PATIENT INFORMATION Patient s Last Name: First: Middle: Nickname: Social Security: Salutation: Mr. Mrs. Ms.

[Address/ P.O Box, City, ST ZIP Code] Ethnicity: Not Hispanic orlatino Hispanic or Latino Home Phone No.: Cell Phone No.: Work Phone No.

1 Demographic Information Form Today s Date: PATIENT INFORMATION Patient s Last Name: First: Middle: Nickname: Social Security: Salutation: Mr. Mrs. Ms. Sex: Male Female Birth Date: Primary Language: Race: American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander White Black or African American Declined To Answer Address: [Address/ P.O Box, City, ST ZIP Code] Ethnicity: Not Hispanic orlatino Hispanic or Latino Home Phone No.: Cell Phone No.: Work Phone No.: (include extension) Marital status: How did you hear about us? TV Radio Google Internet Friend Other, Please specify Were you referred by your doctor? If so, please list the doctor's name: Other family members seen here: RESPONSIBLE PARTY Responsible Party Same As Patient Birth Date: Sex: Male Female Last Name: First: Middle: Address: [Address/ P.O Box, City, ST ZIP Code] Home Phone No.: Cell Phone No.: Work Phone No.: (include extension) Social Security: Emergency Contact Name: Phone: Relationship: Turnover ---->

2 Insurance Information Form Primary Insurance Information Today s Date: INSURED INFORMATION Insured is: Same as patient Same as Responsible Party Carrier Insurance Name: Last name: First Name: Middle Initial: Birth Date: Relationship to Insured: Self Dependent Spouse Policy Number: Group Number: Secondary Insurance Information (If applicable) INSURED INFORMATION Insured is: Same as patient Same as Responsible Party Carrier Insurance Name: Last name: First Name: Middle Initial: Birth Date: Relationship to Insured: Self Dependent Spouse Policy Number: Group Number: The above information is true to the best of my knowledge. I authorize my insurance benefits to paid directly to Peak Vision Center. I understand that I am financially responsible for any balance. I also authorize Peak Vision Center or insurance company to release any information required to pay my claims. I have received and signed the Financial Policy of Peak Vision Center I have received and signed a copy of the Notice of Medical Information Privacy Rights for Peak Vision Center If you have an account that is turned over to collections you will be responsible for your balance, attorney fees, and collection fees. I may be responsible for a refraction fee of and I understand Medicare will not pay that fee. I may be responsible for facility, anesthesia, and laboratory fees. I understand there is a no show fee of Patient/Guardian Signature Today's Date Disclosure: Our patients have the right to know the financial interest or ownership in hospitals and/or facilities. Dr. Chang and Dr. Burden have ownership in Premier Surgery Center and Skyline Surgery Center.

Health History Form Please Fill Out Entire Form Name: Primary Physician: Referring Provider: Review of Symptoms: Check all that apply Date of Birth: Phone: Additional Concerns: Eyes: Blurry Vision

$Eye History: Date Diagnosed Date Surgery Date Diagnosed Date Surgery Cataract Retina Problem Glaucoma Eyelid Eye Muscle Refractive Other Current Eye Medications: Current Medications and Usage: Over$

3 Health History Form Please Fill Out Entire Form Name: Primary Physician: Referring Provider: Review of Symptoms: Check all that apply Date of Birth: Phone: Additional Concerns: Eyes: Blurry Vision Burning/Dryness Double Vision Excess Tearing/Watering Loss of Vision Loss of Side Vision Pain or Soreness Redness Itching/Scratching Seeing at a Distance Glare/Light Sensitivity Reading In General Eye History: Date Diagnosed Date Surgery Date Diagnosed Date Surgery Cataract Retina Problem Glaucoma Eyelid Eye Muscle Refractive Other Current Eye Medications: Current Medications and Usage: Over the Counter Medication: Allergies to Medicines: Height: Weight: Surgical History (with dates): Family History (Check those that Apply and Write the Relationship to you) Cataract Glaucoma Macular Degeneration Blindness Cancer Diabetes Cardiovascular Disease Stroke Other Major Illness or Hereditary Disorder Turn over --->

4 Medical History: Check all that apply Constitutional Systems Fever Weight Loss/Weight Gain Trouble Sleeping/Insomnia Cardiovascular Congestive Heart Failure Heart Attack/Coronary Stent Arrhythmia (AFib, tachy, etc) High Blood Pressure Elevated Cholesterol History of Bypass Surgery Pacemaker/ICD Ears, Nose, Mouth, Throat Hearing Problems/Tinnitus Sinus Congestion Respiratory Emphysema Asthma Lung Cancer Sleep Apnea COPD Chronic Cough/Bronchitis Oxygen Use Neurological Migraines/Headaches Seizures/Epilepsy Stroke Multiple Sclerosis Parkinson s Disease Alzheimer s/dementia Vertigo Gastrointestinal Psychiatric Hepatitis Depression/Bipolar Ulcers/Bleeding Anxiety Stomach/Bowel Cancer PTSD G.E.R.D/Acid Reflux Schizophrenia Genitourinary Enlarged Prostate/Prostate Cancer Cervical/Ovarian/Uterine Cancer Kidney Disease Overactive Bladder Currently Pregnant Musculoskeletal Osteopenia/Osteoporosis Degenerative (Osteo) Arthritis Gout Bell s Palsy Fibromyalgia Integumentary Shingles Skin Cancer Eczema/Psoriasis Hematologic/Lymphatic Anemia/Sickle Cell Hemophilia Leukemia Lymphoma Lyme Disease Mentally Disabled Endocrine Type 1 Diabetes Type 2 Diabetes Hypothyroidism Hyperthyroidism Breast Cancer Allergic/Immunologic Seasonal Allergies/Hay Fever Rheumatoid Arthritis Sjogren s (dry eye/mouth) Lupus HIV Other Immune Disorder Social History Latest Hgb/A1c Alcohol Everyday Occasional None Tobacco Heavy Light Chew Never Former Drugs Marijuana Other None Exercise Yes No Explanation of Other Diagnosed Medical Condition Not Listed: Date: Signature:

5 OUR FINANCIAL POLICY We are committed to providing you with the highest level of service and quality care. If you have medical insurance, we will strive to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our financial policy. Ultimately, however, any and all financial liability rests with the patient. Our office participates with most major insurance plans. We provide VISION, MEDICAL and SURGICAL ophthalmologic & optometric care to our patients. If you have a managed care plan that requires a referral to see a specialist, you must obtain a referral in order for your visit in our office to be covered under your medical insurance. If you do not have the valid referral and still wish to be seen, you will be asked to pay for the visit prior to your examination. A refractive examination is not a covered service by most insurance companies, including Medicare. If you receive a prescription for glasses, you will be charged a refraction fee which is payable at the time of the visit. It is the patient s/parent s/guardian s responsibility to: - Be familiar with the benefits of your plan, including co-pays, co-insurance and deductibles. - Bring all of your current insurance cards to all visits. - Provide our office with current information including address, phone numbers and employer. - In accordance with your insurance contract, you must be prepared to pay your co-pay at each visit. We accept cash, checks and all major credit cards for services. We appreciate prompt payment in full for any outstanding balance. If you are unable to pay a balance in full, please notify our billing department immediately and we will try to work out a payment plan with you. If your account is turned over to our collection agency, you agree to pay any fees imposed by the collection agency in order to collect the overdue amount. Any check payments that do not clear the bank will be subject to a returned check fee. For all services rendered to minor/dependent patients, we will look to the adult accompanying the patient and/or the parent or guardian with whom the child resides for payment. In cases of separation or divorce, when presenting insurance cards for a dependent enrolled under a subscriber other than you, please be prepared to supply their name, address, phone number, date of birth and social security number. We request that you inform the subscriber that their insurance has been used. Due to the nature of our practice we perform surgeries, minor procedures, and a variety of lab services. You will be billed separately from these entities. There will be a $30.00 charge if you fail to show for any scheduled appointments or cancel the same day as your appointment. I have read and understand the above financial policy. Signature of patient/guardian/parent Printed name of patient Date Date

6 SUMMARY NOTICE OF PRIVACY PRACTICES THIS IS A SUMMARY OF OUR NOTICE OF PRIVACY PRACTICES, WHICH DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The notice contains Patient rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. You may obtain a copy by asking the front desk or Privacy Officer. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy. Our pledge to protect your privacy: Skyline Vision Clinic and Laser Center is committed to protecting the privacy of your medical information. Your care and treatment is recorded in a medical record. So that we can best meet your medical needs, we share your medical record with the providers involved in your care. We share your information only to the extent necessary to collect payment for the services we provide, to conduct our business operations, and to comply with the laws that govern health care. We will not use or disclose your information for any other purpose without your permission. Patient Rights - You have the following rights regarding your medical information: to request to inspect and obtain a copy of your medical records, subject to certain limited exceptions; to request to add an addendum to or correct your medical record; to request an accounting of Skyline Vision Clinic and Laser Center disclosures of your medical information; to request restrictions on certain uses or disclosures of your medical information; to request that we communicate with you in a certain way or at a certain location; and to receive a copy of the full version of our Notice of Privacy Practices. We may use and disclose medical information about you for the following purposes: to provide you with medical treatment and services; to bill and receive payment for the treatment and services you receive; for functions necessary to run Skyline Vision Clinic and Laser Center and assure that our Patients receive quality care; to provide basic contact information (no medical information is provided) to our development office for purposes of fundraising for Skyline Vision Clinic and Laser Center; to support our standing as a federally qualified health center; and as required or permitted by law.

ACKNOWLEDGEMENT OF RECEIPT OF SUMMARY NOTICE OF PRIVACY PRACTICES Revised May 17, 2018 By signing this form, you consent to our use and disclosure of protected health information about you for

7 ACKNOWLEDGEMENT OF RECEIPT OF SUMMARY NOTICE OF PRIVACY PRACTICES Revised May 17, 2018 By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke the Consent in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. Skyline Vision Clinic and Laser Center provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Name of Patient (print) Signature of Patient Date Signature of Patient Representative Relationship to Patient Date (Required if Patient is a minor or an adult who is unable to sign this form) I understand that my health care and the payment for my health care will not be affected if I do not sign this form initials Communication Preferences: Home phone number: Mobile phone number: In caring for our patients, it may be necessary for Skyline Vision Clinic and Laser Center staff to contact you by phone. When we are not able to speak to you directly, we like to leave messages when possible. In order to protect your privacy, it is Skyline Vision Clinic and Laser Center s policy to not leave messages with anyone except the patient or legal guardian, nor leave specific information on an answering machine/voic system unless we have your written permission to do so. Yes, I want you to leave a voice mail. (Please circle) Home Mobile No, I do not want you to leave a voice mail. Skyline Vision Clinic and Laser Center may disclose your medical information such as exams, labs/radiology results, appointments and your insurance or billing information to the following people: Name Relationship Phone Number Name Relationship Phone Number Name Relationship Phone Number Name Relationship Phone Number No, I do not want you to discuss my medical care with anyone other than me. I request removal from lists that initiate promotional or marketing communications Yes: initials

Demographic Information Form

Demographic Information Form Today s Date: PATIENT INFORMATION Patient s Last Name: First: Middle: Nickname: Social Security: Salutation: Mr. Mrs. Ms. Sex: Male Female Birth Date: Primary Language: Race: