NEW PATIENT COMPLETE EYE EXAM WILL TAKE 1-2 HOURS - YOUR EYES WILL BE DILATED

Transcription

1 PLEASE COMPLETE ALL OF THE ENCLOSED FORMS AND BRING THEM WITH YOU AT THE TIME OF YOUR APPOINTMENT. FAILURE TO DO SO WILL DELAY YOUR APPOINTMENT. Cancellatins require 24 business hurs ntice. Appintments nt kept r cancelled prir t 24 hurs will be assessed a $30.00 n shw fee. PLEASE BRING THE FOLLOWING ITEMS WITH YOU AND PRESENT AT TIME OF CHECK-IN Cmpleted paperwrk Insurance cards (Medical and Visin) Picture ID List f all MEDICATIONS yu take with strengths and dsages Cntact Lens wearers bring written prescriptin r bxes they came in Primary Care Physician s name and telephne Preferred pharmacy and telephne NEW PATIENT COMPLETE EYE EXAM WILL TAKE 1-2 HOURS - YOUR EYES WILL BE DILATED Turn nt Prfessinal Parkway frm Hspital Drive (This is the nly stp light between the hspital and the curthuse.) G t the end f the street, the 6001 Prfessinal Building is n the right PROFESSIONAL PARKWAY SUITE 2040 DOUGLASVILLE, GA

2 WELCOME TO DOUGLASVILLE EYE CLINIC, P.C. (PLEASE PRINT CLEARLY) PATIENT INFORMATION: Preferred Name: LEGAL NAME: First M.I. Last SEX: Male Female MARITAL STATUS: Single Married Divrced Widwed Other OF BIRTH: / / AGE: SOCIAL SECURITY #: - - ETHNICITY: Nn-Hispanic/Latin Mexican Puert Rican Cuban Other Hispanic/Latin RACE: White Black/African American Hispanic/Latin Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander DECLINE TO ANSWER PREFERRED LANGUAGE: English Spanish Other: ADDRESS: CITY: _ STATE: ZIP: PRIMARY PHONE: CELL: HOME: ADDRESS: OCCUPATION: EMERGENCY CONTACT NAME: PHONE: PRIMARY MEDICAL INSURANCE NAME: MEMBER #: GROUP #: POLICY HOLDER RELATIONSHIP TO THE PATIENT: SELF SPOUSE CHILD OTHER: SECONDARY MEDICAL INSURANCE NAME: MEMBER #: GROUP #: POLICY HOLDER RELATIONSHIP TO THE PATIENT: SELF SPOUSE CHILD OTHER: VISION INSURANCE NAME: MEMBER #: GROUP #: POLICY HOLDER RELATIONSHIP TO THE PATIENT: SELF SPOUSE CHILD OTHER: FINANCIAL INFORMATION PERSON RESPONSIBLE FOR THE BILL: NAME: RELATIONSHIP: PHONE: ADDRESS: CITY: _ STATE: ZIP: WHO MAY WE THANK FOR REFERRING YOU?

3 DOUGLASVILLE EYE CLINIC MEDICAL HISTORY RECORD Patient Name: Date f Birth: Medical Dctrs name: Referring Dctrs name: Preferred Pharmacy: Lcatin/Phne#: Are yu allergic t any medicatin? NONE KNOWN YES, Please list Are yu allergic t LATEX? Yes N D yu currently take ANY prescriptin r ver the cunter medicatin? NO YES, PLEASE LIST HERE OR PROVIDE A LIST OF ALL MEDICATIONS INCLUDING STRENGTH AND DOSAGE. Have yu ever taken FLOMAX r any ther prstate medicatin? Yes N DISCONTINUED List any EYE DROPS yu are currently using and hw ften: NONE Artificial Tears D yu have any past r present prblems in the fllwing areas, please CIRCLE Yes r N: IF YES PLEASE EXPLAIN. Yes N General prblems _ Yes N Ears, Nse, Thrat, Muth _ Yes N Lungs/Breathing _ Yes N Heart/Bld Vessels/Bld pressure/chlesterl Yes N Skin/Hair _ Yes N Stmach/Intestines _ Yes N Prstate/Kidney/Bladder _ Yes N Endcrine/Diabetes/Thyrid/Hrmnes/Graves Yes N Neurlgical/Brain/Nerves _ Yes N Psychiatric/Anxiety/Depressin _ Yes N Hematlgic/Bld/Lymph _ Yes N Musculskeletal/Jints _ Yes N Allergic/Immune Disrder/HIV/AIDS _ Yes N Cancer If yes what type? : Currently underging treatment? Yes N Scial Histry: Yes N Tbacc Use: If yes, pack(s)/day fr years. DISCONTINUED Yes N Alchl Use: If yes, hw much hw ften fr years. DISCONTINUED Past and/r present EYE prblems including EYE surgeries: Surgical Histry: List ANY ther surgeries yu have ever had r check nne: NONE Family Histry: RELATIONSHIP RELATIONSHIP Yes N Glaucma Yes N Macular Degeneratin Yes N Diabetes Yes N Retinal Disease

4 DOUGLASVILLE EYE CLINIC, P.C. REFRACTION AND CONTACT LENS AGREEMENT Refractin (checking fr eyeglass prescriptin change) may be perfrmed fr the purpse f giving the patient a new eyeglass prescriptin r as a diagnstic test t help understand why a patient s visual acuity might be decreased. Duglasville Eye Clinic has advised me that the refractin (checking fr eyeglass prescriptin) is usually nt cvered by my MEDICAL insurance. It may be cvered by sme visin plans r if I carry visin benefits under my medical insurance plan. It is the patient s respnsibility t ntify Duglasville Eye Clinic as t what their visin plan is and t verify that ur physicians are participating in their insurance prir t their appintment. I UNDERSTAND THAT IF I CHOOSE NOT TO HAVE REFRACTION I WILL NOT RECEIVE A GLASSES PRESCRIPTION. I agree t pay fr refractin at the time f service and if my medical insurance des pay Duglasville Eye Clinic fr this service, I will be reimbursed by Duglasville Eye Clinic in a timely matter. CPT DESCRIPTION CHARGE Refractin $35.00 CONTACT LENS FITTING PRICE RANGE We prvide services fr fitting MOST types f cntact lenses. Hwever, there is an additinal fee fr these services. Many times insurance will NOT cver this fee as it is nt part f a rutine eye exam. REFIT-CURRENTLY WEARING CONTACT LENSES $40.00-$ NEW FIT-NEVER WORN CONTACT LENSES $ $ This fee will be required annually as Gergia State Law mandates cntact lens prescriptins are valid fr 12 mnths. The fitting fee des nt include the cst f any lenses. Exact fitting fee is determined by ne f ur licensed pticians. IF YOU ARE CURRENTLY WEARING CONTACT LENSES, BRING EITHER YOUR MOST RECENT CONTACT LENS PRESCRIPTION OR CONTACT LENS CONTAINERS. WITHOUT BRAND NAME, POWER, DIAMETER AND BASE CURVE, A RE FIT WILL BE REQUIRED. It is imprtant that patients keep their fllw-up appintments fr cntact lens evaluatins. Failure t keep these appintments can result in additinal fees after 30 days.

5 DOUGLASVILLE EYE CLINIC, P.C. FINANCIAL AND PRIVACY POLICIES DISCLOSURE FORM FINANCIAL AGREEMENT AND HIPAA INFORMATION: We require 24 hur cancellatin ntice. Appintments nt kept and nt cancelled within 24 business hurs f the appintment time will be assessed a $30.00 n shw fee. Payment is expected at the time f the visit fr any amunts due. This includes but is nt limited t c-payments, deductibles and nn-cvered charges. Cmplete MEDICAL and VISION cverage must be prvided prir t services. -A claim fr services will be filed immediately upn cmpletin f services n the infrmatin prvided. We nly accept visin plans requiring prir authrizatins when ntified f the cverage prir t services. Pht ID and prf f insurance must be presented at check-in. Change f patient name r insurance must be advised at check-in. Returned checks are assessed a $30.00 return check fee. All fees are subject t change withut ntice. An phthalmic exam des NOT include a cntact lens fitting. A fitting fr cntact lenses will be prvided upn my request fr an additinal charge. THE PATIENT IS RESPONSIBLE FOR verifying that ur physicians are participating n their plan. THE PATIENT IS RESPONSIBLE FOR btaining authrizatins/referrals when required by their insurance cmpany. THE PATIENT IS RESPONSIBLE FOR understanding their OWN insurance plicy. -ANY infrmatin prvided by Duglasville Eye Clinic staff is nt a guarantee f benefits r cverage. Insurance cmpanies state that benefits are nly determined nce a claim is prcessed. ASSIGNMENT OF BENEFITS TO DOUGLASVILLE EYE CLINIC, P.C.: I hereby authrize Duglasville Eye Clinic, t release any infrmatin t my insurance cmpany fr services rendered t my dependents r t myself in the prcessing f this claim. I authrize claims t be filed t my insurance plan and payment t be made directly t Duglasville Eye Clinic. This assignment will remain in effect until revked by me in writing. MEDICARE PATIENTS ONLY: I request that payment f authrized Medigap benefits be made n my behalf t Duglasville Eye Clinic fr any services furnished by supplier. I authrize any hlder f medical infrmatin abut me t be released t including infrmatin needed t determine benefits payable fr related services. (Name f Medicare secndary insurer) PRIVACY POLICY: I acknwledge that I have been made aware that Duglasville Eye Clinic, P.C. has a Privacy Plicy in place in accrdance with the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA). I understand that, upn request, I am entitled t a cpy f the Privacy Plicy. AGREEMENT FOR COMMUNICATION: I authrize Duglasville Eye Clinic, P.C. t cntact me in the fllwing ways t remind me f appintment, prvide test results, instructins, r any ther infrmatin. Hme phne YES NO VOIC OK? Wrk phne YES NO VOIC OK? Cell phne YES NO VOIC OK? (Only used n a secure server as required by law) YES NO I authrize the release f medical infrmatin t: NAME: RELATIONSHIP: PHONE: I have read, understand, and agree t this financial statement. I hereby vluntarily cnsent t treatment at this ffice and authrize treatments, examinatins, medicatins, anesthesia, peratins and diagnstic prcedures (this includes but is nt limited t the use f lab and radigraphic studies) as rdered by the attending physician.

6 NOTICE OF PATIENT PRIVACY PRACTICES REVISION 11/12/2014 A. OUR COMMITMENT TO YOUR PRIVACY- The terms f this ntice apply t all recrds cntaining yur PHI. We reserve the right t revise r amend this Ntice f Privacy Practices. Any revisin r amendment t this ntice will be effective fr all yur recrds that ur practice has created r maintained in the past, and fr any f yur recrds that we may create r maintain in the future. Our practice will pst a cpy f ur current Ntice in ur ffices in a visible lcatin at all times, and yu may request a cpy f ur mst current Ntice at any time. B. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Cmpliance Officer C. WE MAY USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS: 1. Treatment. 2. Payment. 3. Health Care Operatins. 4. Appintment Reminders. 5. Treatment Optins. 6. Health-Related Benefits and Services. 7. Our practice may release yur PHI t a friend r family member that is invlved in yur care, r wh assists in taking care f yu. 8. Disclsures Required by Law. D. USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES 1. Public Health Risks. 2. Health Oversight Activities. 3. Lawsuits and Similar Prceedings. 4. Law Enfrcement. 5. Deceased Patients. 6. Organ and Tissue Dnatin. 7. Research. 8. Serius Threats t Health r Safety. 9. Military. 10. Natinal Security. 11. Inmates. 12. Wrkers Cmpensatin. E. YOUR RIGHTS REGARDING YOUR PHI. Yu have the fllwing rights regarding the PHI that we maintain abut yu: 1. Cnfidential Cmmunicatins. 2. Yu have the right t request a restrictin in ur use r disclsure f yur PHI. 3. Inspectin and Cpies. Yu have the right t inspect and btain a cpy f the PHI. 4. Amendment. Yu may ask us t amend yur health infrmatin if yu believe it is incrrect r incmplete, and yu may request an amendment fr as lng as the infrmatin is kept by r fr ur practice. 5. Accunting f Disclsures. All f ur patients have the right t request an accunting f disclsures.. 6. Yu are entitled t receive a paper cpy f ur ntice f privacy practices. 7. If yu believe yur privacy rights have been vilated, yu may file a cmplaint with ur practice r with the Secretary f the Department f Health and Human Services. Cmplaints must be submitted in writing t Attn: Cmpliance Officer. 8. Our practice will btain yur written authrizatin fr uses and disclsures that are nt identified by this ntice r permitted by applicable law.

7 Discriminatin is Against the Law Duglasville Eye Clinic PC cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. Duglasville Eye Clinic PC des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. Duglasville Eye Clinic PC Prvides free aids and services t peple with disabilities t cmmunicate effectively with us, such as: Qualified sign language interpreters Written infrmatin in ther frmats (large print, audi, accessible electrnic frmats, ther frmats) Prvides free language services t peple whse primary language is nt English, such as: Qualified interpreters Infrmatin written in ther languages Grievance Prcedure If yu believe that Duglasville Eye Clinic PC has failed t prvide these services r discriminated in anther way n the basis f race, clr, natinal rigin, age, disability, r sex, yu can file a grievance with: Stacey Osterhlt, Cmpliance Officer 6001 Prfessinal Parkway Suite 2040 Duglasville, GA Telephne number , Fax cntact@duglasvilleeyeclinic.cm Yu can file a grievance in persn r by mail, fax, r . If yu need help filing a grievance, Stacey Osterhlt, Cmpliance Officer is available t help yu. Yu can als file a civil rights cmplaint with the U.S. Department f Health and Human Services, Office fr Civil Rights, electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, available at r by mail r phne at: U.S. Department f Health and Human Services If yu need these services, cntact Stacey Osterhlt. 200 Independence Avenue, SW Rm 509F, HHH Building Washingtn, D.C , (TDD) Cmplaint frms are available at