Welcome to Mills Eye + Facial Surgery!!

Transcription

1 182 E. Redstone 1300 Shoreline Dr University Pkwy. Ste. A Ste. 104 Pensacola, FL Welcome to Mills Eye + Facial!! Dr. Mills and his staff are excited to add you to our growing family of patients. We know that you have a choice when it comes to health care and we sincerely appreciate you choosing our practice to serve your needs. *Please look carefully at any attachments to this . They include information, privacy, consent, and other important forms. You should print them, read them, sign them, and bring them with you to your appointment. Keep in mind that some forms are general to all patients and some are specific to the reason for your appointment. Also, we may send you further s with information specific to your reason for visit, so please watch for them as well. If you feel that the forms do not apply to the reason for your visit, simply return them to us when you come. *Please also look at the instructions below to access the online portal prior to your appointment. This is a secure way to help us acquire the necessary information to expedite your visit. We know that the relationship between a doctor and patient is a critical element to the health care experience. We understand the importance of your eyes and vision as well as your face and appearance. Therefore, Dr. Mills and his staff have spared no effort or expense in pursuing the best possible training available and the latest cutting edge technology to provide you with the very best they have to offer in eye care and facial surgery. However, even if you were referred to us by your doctor, family member, or friend, it s still natural for you to have some questions regarding the providers here at the practice and their training/specialization or about the practice in general. We would first refer you to visit our website at to learn more about Dr. Mills, and the other providers and staff at Mills Eye + Facial. This will be a great resource to you as our patient now and in the future. However, we have provided here some details for your immediate review. We hope it allows you to begin your relationship with us with the confidence that you are in the expert hands of superbly trained, well-recognized, leaders and teachers. David M. Mills, MD, FACS Dr. Mills originally obtained his undergraduate degree in Biochemistry Summa Cum Laude with Departmental Honors from Wheaton College in Norton, Massachusetts before receiving his Medical Degree from the University of Michigan Medical School. He completed a Transitional Year Internship at Oakwood Hospital in Dearborn, Michigan then headed south to complete Residency Training in Ophthalmology at the University of Florida- Gainesville. Dr. Mills then went on to Albany, New York for a 2-year fellowship in OculoFacial Plastic, Reconstructive, and Cosmetic accredited by the American Society of Ophthalmic Plastic and Reconstructive (ASOPRS). Plastic As one of the few surgeons to be certified by both the American Board of Ophthalmology and the American Society of Ophthalmic Plastic and Reconstructive (ASOPRS), Dr. Mills unique expertise distinguishes him as a premier surgeon. Dr. Mills is also one of the few (if not the only) Oculos in the region to have completed 2 years of ASOPRS-Accredited fellowship training. Dr. Mills is or has been a(n): Diplomate, American Board of Ophthalmology (ABO) Page 1 of 2

2 182 E. Redstone 1300 Shoreline Dr University Pkwy. Ste. A Ste. 104 Pensacola, FL Fellow, American Society of Ophthalmic Plastic and Reconstructive, Inc. (ASOPRS) Fellow, American Academy of Cosmetic (AACS) Fellow, American Academy of Facial Plastic and Reconstructive (AAFPRS) Member, American Society for Laser Medicine & (ASLMS) Fellow, American College of Surgeons (ACS) Active Fellow, American Academy of Ophthalmology (AAO) American Society of Cataract and Refractive member (ASCRS) American Medical Association member (AMA) Florida Medical Association member (FMA) Florida Society of Ophthalmology member (FSO) Plastic Page 2 of 2

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4 182 E. Redstone 1300 Shoreline Dr University Pkwy. Ste. A Ste. 104 Pensacola, FL Agreement Form for Communications Between Mills Eye + Facial Providers & Patient 1. Secure electronic messaging is always preferred to insecure for more sensitive Protected Health Information (PHI), but under specific circumstances, insecure communication containing PHI may take place between a Mills Eye + Facial (MEFS) provider and a patient. This communication may be used if both parties agree on this communication method and this form is completed and signed by the patient or the patient s personal representative (if appropriate). 2. A copy of this form will be filed in the patient s Medical Record and a hard copy of this form will be provided to the patient (via or paper). This agreement is limited to communications using the addresses listed below. 3. Provider Awareness: a. Standard is not a secure means of communication, so as the provider I will use the minimum necessary amount of protected health information when responding to your questions or communicating information to you. In no event will my communications include highly sensitive PHI such as information relating to HIV/AIDS, mental health or substance abuse. 4. Patient Awareness: a. Please note that most standard does not provide a secure means of communication. There is some risk that any protected health information contained in may be disclosed to, or intercepted by, unauthorized third parties. Use of more secure communications, such as phone or fax, is always an alternative that is available to you. 5. By completing this form, the provider and I understand and are willing to accept the risks involved with insecure communication of my protected health information. Patient s Name (printed): Date: / / Patient s Address (print): Plastic Patient s Signature: Page 1 of 2

5 182 E. Redstone 1300 Shoreline Dr University Pkwy. Ste. A Ste. 104 Pensacola, FL Withdrawal of Agreement for Communication 6. Should either party no longer wish to communicate via , please complete the form below and deliver in person or send by U.S. Postal Service to the other party. A copy of the form will be filed in the patient s medical record. a. I no longer wish to communicate via . Date: / / Name (print name): Address (print): Signature: Change of Address 7. Should either party change their address, please complete the information below and deliver in person or send by U.S. Postal Service to the other party. A copy of this form will be filed in the patient s medical record. a. I am changing the address to be used for communication with my provider. Date: Name (print name): / / Old Address (print): New Address (print): Signature: Plastic Page 2 of 2

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7 182 E. Redstone 1300 Shoreline Dr University Pkwy Ste. A Ste. 104 Pensacola, FL Authorization, Assignment of Benefits, Financial Agreement: Plastic 1. It is the responsibility of the patient to review his/her insurance coverage and to know if a referral is necessary, precertification is required, or a second opinion in necessary. 2. Co-pays, Co-insurance and deductibles are due at the time of service and are collected at check in. 3. Payment arrangements and billing questions can be done through our billing office at (850) MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Mills Eye + Facial for services furnished me by their providers. I authorize any holder of medical information to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits pay-able for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay any and all claims. If other health insurance in indicated in Item 9 of the CMS-1500 form or elsewhere on the approved claim forms, my signature authorizes releasing information to the insurer or agency shown. Mills Eye + Facial accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance, and noncovered services. Coinsurances and deductible are based upon the charge determination of the Medicare carrier. 5. SECONDARY/MEDIGAP: I understand that if a Secondary/MediGap policy or other health insurance is indicated in Item 9 of the CMS-1500 claim form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Mills Eye + Facial. 6. OTHER INSURANCE: I understand that Mills Eye + Facial maintains a list of health care service plans with which it contracts. A list of such plans is available from the business office and that Mills Eye + Facial has no contract, expressed or implied, with any plan that does not appear on the list. I understand and agree that I am individually obligated to pay the full charges of all services rendered to me by Mills Eye + Facial if I belong to a plan that does not appear on the above mentioned list. 7. NON-COVERED SERVICES: I understand that Mills Eye + Facial s contracts with health care service plans (i.e., HMOs, PPOs) relate only to items and services which are covered by the health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services determined by the health care service plans not to be covered. Examples of non-covered services include, but are not limited to, services not specified as being covered in the patients contract with a health care service plan or the benefit summary the health care service plan furnishes to the patient and treatment or tests not authorized by the health care service plan. 8. RELEASE OF INFORMATION: Mills Eye + Facial may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to Mills Eye + Facial for reimbursement of services rendered, and (2) any health care provider for continued patient care. A copy of this authorization may be used in place of the original. 9. FINANCIAL AGREEMENT: I agree that in return for the services provide to the patient by Mills Eye + Facial, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Mills Eye + Facial payment. An account with a patient balance that receives NO RE-SPONSE AFTER 60 DAYS may be sent to an attorney or collection agency for collection. I agree to pay collection expenses and reasonable attorney s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to Mills Eye + Facial. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill/account. 10. CONSENT OF TREATMENT: I hereby grant my authorization and consent for medical treatment and procedures for myself and/or minor children, and certify Page 1 of 2

8 182 E. Redstone 1300 Shoreline Dr University Pkwy Ste. A Ste. 104 Pensacola, FL that no guarantee or assurance has been made as to the results which may be obtained. Patient Name (please print): DOB: / / Signature of Patient or Guarantor: Date: / / Plastic Page 2 of 2

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10 182 E. Redstone 1300 Shoreline Dr University Pkwy Ste. A Ste. 104 Pensacola, FL HIPAA Notice of Privacy Practices This notice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected Health Information is information about you, including demographic information that may identify you, that relates to your past, present, or future physical or mental health or condition and related health services. 1. Uses and Disclosures of Protected Health Information- Your protected health information may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician s practice, and any other use required by law. a. Treatment- We will use and disclose your protected health information to provide, coordinate, or manage your health care and related services. This includes the coordination or management of your healthcare with a 3rd party. For example, we would disclose your information as necessary to a home health agency that cares for you or to a physician to whom you have been referred to ensure the physician has the necessary information to diagnose and treat you. b. Payment- Your protected health information will be used, as needed, to obtain payment for your health care services. c. Healthcare Operations- We may use or disclose, as needed, your protected health information in order to support the business activities of your physician s practice. These activities include, but are not limited to, appointment reminders, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call your name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information in the following situations without your authorization: as required by law, Public Health issues as required by law, Communicable diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration, Legal Proceedings, Law Enforcement, Coroners, Funeral Directors, and Organ Donation, Research, Criminal Activity, Military Activity and National Security, Worker s Compensation, Inmates. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or opportunity to object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or physician s practice has taken an action in reliance on the use or disclosure indicated in the authorization. Plastic YOUR RIGHTS: You have the right to inspect and copy your protected health information. However, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You have the right to request a restriction of your information. You have the right to request confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically. You have the right to request your physician amend your protected health information. You have the right to receive an accounting of certain disclosure we have made, if any, of your protected health information. Page 1 of 2

11 182 E. Redstone 1300 Shoreline Dr University Pkwy Ste. A Ste. 104 Pensacola, FL Complaints: You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy officer of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask us to explain. Signature below confirms acknowledgement and receipt of a copy of our Privacy Practices (HIPAA). Signature: Print Name: Date: / / Person (s) to be compliant with HIPAA for Mills Eye + Facial Medical and Demographic chart for Patient Protected Health Information. 1. Relationship 2. Relationship 3. Relationship Plastic Page 2 of 2

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13 182 E. Redstone 1300 Shoreline Dr University Pkwy. Ste. A Ste. 104 Pensacola, FL Medical History Questionnaire Patient: DOB: / / Today s Date: / / Plastic Reason for today s visit: Name of Primary Medical Doctor: Dr. s Phone: ( ) Dr s City/State: Medical History Last Medical Exam: / / Do you have any allergies to medications? no yes if yes, explain: List any medications you take: List all major injuries, surgeries, and/or hospitalizations you have had: List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections, or eye injury: Are you pregnant and/or nursing? no yes Do you wear glasses? no yes If yes, how old is your present pair of lenses? Do you wear contact lenses? no yes Family History Please note any family history (parents, grandparents, siblings, children; living or deceased) for the following conditions: Disease/Condition No Yes? Relationship to You Blindness Cataract Crossed Eyes Glaucoma Macular Degeneration Retinal Detachment/Disease Arthritis Cancer Diabetes Heart Disease High Blood Pressure Page 1 of 2

14 182 E. Redstone 1300 Shoreline Dr University Pkwy. Ste. A Ste. 104 Pensacola, FL Kidney Disease Lupus Thyroid Disease Other: Social History This information is kept strictly confidential. However, you may discuss this portion with the doctor if you prefer. Yes, I would prefer to discuss my Social History information directly with my doctor. Do you drive? no yes If yes, do you have visual difficulty when driving? no yes If yes, please describe: Do you use tobacco products? no yes If yes, type/amount/how long: Do you drink alcohol? no yes If yes, type/amount/how long: Do you use illegal drugs? no yes If yes, type/amount/how long: Mark if you have ever been exposed to or infected with (If not, leave blank): Gonorrhea Hepatitis HIV Syphilis Plastic Page 2 of 2

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16 Patient Information as of (enter today s date) (Please Print Legibly & Fill In or Correct All Fields) Patient s Name Address Last First Middle «Street & Apt # City State Zip Home Phone Cell Phone Other Phone Any restrictions for contacting you? No Yes Contact Drivers License # Restrictions: (include State) Age Birthdate / / SS# - - Sex Female Male Marital Status Single Married to: Other: Patient s Employer Occupation Work Phone Ext: Is it okay to call you at work? Yes No Address Emergency Contact (Not in your household) Street & Suite # City State Zip Relationship to Patient Home Phone Work Phone Other Phone Address Primary Health Insurance Company Street & Apt # City State Zip Policy # Group # Ins. Phone Referral Required? No Yes Copay? No Yes, $ Insured: Name DOB Employer Secondary Health Insurance Company Policy # Group # Ins. Phone Referral Required? No Yes Copay? No Yes, $ Insured: Name DOB Employer I understand that office visit charges are payable on the day service is rendered. I authorize Dr. «Doctor_Last_Name» to bill my insurance company. Regardless of insurance coverage, I am responsible for all bills being paid in a timely manner. I understand that my contract is between Dr. «Doctor_Last_Name» and myself. Signature Date

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18 182 E. Redstone 1300 Shoreline Dr University Pkwy Ste. A Ste. 104 Pensacola, FL Mills Eye + Facial Patient Portal Instructions Please visit prior to your appointment and complete any missing information. If done through our secure portal, it will securely and automatically update our system, thereby eliminating some of these time-consuming procedures upon arrival. This can reduce your wait time in our office and provide us with the information we need to provide you with the best possible care. Mills Eye + Facial s Patient Portal allows you to: Complete the demographic information required for us to bill your insurance company Enter your insurance information Complete and/or download forms related to your care Provide us your medical history information View / download clinical care summaries and other educational material (the government is starting to require patients to review this information online) Send the office a secure electronic message Confirm or request appointments To access Mills Eye + Facial s Secure Patient Portal: Step 1: Go to and click Go to patient portal in the Access our patient portal section. Step 2: Your User Name will be your first initial of your first name and the last 4 of your Primary Phone Number (that we have on file) Example: John Smith (850) would be j7500 Plastic Step 3: Your Password is first initial of your last name and the last 4 of your Primary Phone Number (that we have on file) Example: John Smith (850) would be s7500 If you have trouble using or are unable to access your portal please contact our staff for assistance. Page 1 of 1

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20 182 E. Redstone 1300 Shoreline Dr University Pkwy. Ste. A Ste. 104 Pensacola, FL Photograph and Video Release Form: 1. Mills Eye + Facial collects and uses photographs and videos of various procedures and conditions to use in public service endeavors, educational and charitable programs, and teaching program materials. By signing the release below, you are agreeing to allow photographs or videos of yourself, and your medical history connected to the material, to be used by Mills Eye + Facial. If your picture has been taken in reference to a particular medical condition, your name will NOT be used in connection with the photographs or medical information. 2. I DO or DO NOT GIVE MY PERMISSION, without restriction, for consideration received, for Mills Eye + Facial to take, reproduce and publish, in all media including electronic formats known or unknown, photographs or videos of me, or to have this done on their behalf. I understand that these photographs or videos may be used in whole or in part, in informational, educational or commercial publications of any kind (including without limitation, electronic publishing), by Mills Eye + Facial or their affiliated corporations. I understand that although the materials will not contain my name or any other identifying information, I may or may not be identified by the photos. 3. If selecting DO above, I agree that this also grants my permission to use in connection with the photographs or videos, for any purposed whatsoever, all or any portion of any writing, summary, description or synopsis setting forth my medical diagnosis, treatment and results, and also give my permission for my physician to release medical information about my diagnosis, treatment or results in connection with the photographs. I understand my name will not be used in connection with medical information or photographs. Plastic 4. I UNDERSTAND AND AGREE THAT: a. I will not have any right to inspect the finished work or product or to approve its use. b. The originals and all copies of the photographs, videos, and negatives and any copyright rights in them will be owned by Mills Eye + Facial, and it will have all rights to use, not use or dispose of the photographs or videos, in any manner whatsoever. c. I will not retain any rights of privacy or publicity or any other rights I may have in the use of my photographs or videos. d. The agreements in this Release are binding and cannot be changed by me or someone who has been given my rights. ADULTS: Signature: Date: / / Page 1 of 2

21 182 E. Redstone 1300 Shoreline Dr University Pkwy. Ste. A Ste. 104 Pensacola, FL Printed Name: MINORS: Signature of Parent or Guardian: Date: / / Printed Name of Minor: Status: Parent Guardian Plastic Page 2 of 2

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