Dear Patient, See you soon! The Staff at Eye Health Partners

Transcription

1 Dear Patient, Welcome to Eye Health Partners of Middle Tennessee, Inc.! Your doctor has recommended a visit with us and we are looking forward to seeing you. Eye Health Partners is a referral center for medical and surgical eye health disorders. The information in this letter is designed to assist you and provide information about our doctors and services. At Eye Health Partners, you will be treated with respect from each and every doctor and staff member. You can expect clear explanations regarding your eye condition(s) and all possible treatment options available. We are here to help you understand and take care of your eye health needs. one likes to wait in a doctor's office so we do everything we can to minimize your time with us. Please complete the new patient forms you have downloaded prior to your appointment. Having these forms, along with your insurance cards, and a list of your medications, helps us to serve you more quickly. If you are wondering how long your visit will be, please note the following information. Appointments for new patients last approximately two hours because of special testing needed and initial evaluation and counseling. Please allow for appropriate time in your schedule. Follow up visits generally take about an hour. If you are bringing a child to see one of our doctors, please schedule the appointment around nap times and feedings. If other children must accompany you, please arrange for another adult to wait with them in our reception area. This will allow our staff and doctors to focus on the person receiving care. Insurance plans vary. Please remember that you are responsible for any required referrals necessary prior to your visit. Any unmet deductibles, co-payments or co-insurance will be collected when you come in for your visit with us. Remember.to download the new patient forms and bring them along with a list of your current medications and dosages, your insurance cards and your ID to your appointment. See you soon! The Staff at Eye Health Partners

2 BILLING POLICIES The specialists of Eye Health Partners participate with a variety of products from the following insurance plans: Aetna Amerigroup HMO Americhoice HMO Blue Cross Blue Shield Cigna First Health Great West Healthsprings (certain plans only) Humana Humana Military Tricare Medicare and Railroad Medicare Medicaid PHCS Signature Health Alliance United Healthcare Windsor Worker s Compensation **Eye Health Partners providers are medical providers; therefore file with medical insurance and not vision plans. ** t all Eye Health Partners providers participate with all plans listed above. You should call your insurance company to verify the physician you are seeing is in network with your plan. Dr. Bregman also participates with the following LASIK discount plans: Eye Med and VSP. If you are enrolled in one of the insurance plans listed above: We will verify your eligibility and benefits. If it is determined that you have a co-pay, coinsurance or un-met deductible, payment will be due at time of service. If you are unable to make payment at time of service, we will gladly re-schedule your appointment for you. If your insurance plan requires a referral to see a specialist, you are responsible for obtaining the referral. Please have your physician fax it to our office before your appointment. If we do not have your referral before your appointment, we will gladly reschedule your appointment for you. Our office will obtain pre-certification for procedures if it is required with your insurance plan. For all other insurance plans and self pay patients: If we do not participate with your insurance plan, we will be glad to submit a claim on your behalf. However, you are responsible for payment in full. Payment is expected at time of service. When scheduling elective surgery, payment is expected prior to the surgery. If you are unable to make full payment, Care Credit may be an option for you. Please ask one of our surgical coordinators for more information. If you do not have insurance, payment in full is expected at time of service.

3 In accordance with the RED FLAG RULE (Effective vember 1, 2009) all patients must present the following upon checking in for their appointment: A. Driver s license or other photo ID with current address B. Valid health insurance card C. Social Security Number D. Employer for patient and guarantor E. Foreign country passport or government-issued ID card, if no driver s license/photo ID is available F. Utility bills or other correspondence showing current residence, if the photo ID does not show the patient s current address. We cannot treat those without ID. If the requested information cannot be presented, we are happy to see you with fees paid by cash or credit card. We are happy to bill your insurance for today s visit. Insurance co-payments are requested prior to seeing the doctor. You will be responsible for any balance.

4 Patient Information: PATIENT REGISTRATION Patient Name: Social Security #: DOB: Address: City: State: Zip: Home Phone: Work Phone: Cell Phone: Sex:[ ] M [ ] F Marital Status:[ ] Married [ ] Divorced [ ] Single [ ] Widowed [ ] Other Spouse's Name: Spouse's Employer: Spouse's Phone Number: Spouse's Employer Phone Number: Nearest Relative/Relationship: Their Phone number: address: Primary Care Physician: Referring Physician/Optometrist Phone Number: Patient Employment: [ ] Employed [ ] Retired [ ] Student [ ] Other Occupation: Employer: Employer Phone Number: Guarantor Information (person responsible for today's fees): [ ] Same as Patient [ ] Spouse [ ] Guardian [ ] Other Guarantor Name: Relationship to Patient: Address: City: State: Zip: Guarantor's DOB: Social Security #: Driver's Lic #: Guarantor's Home Phone: Cell Phone: Guarantor's Employer: Employer Phone Number: Patient Insurance Information: Primary Insurance: Insured: Relationship to Patient: Insured DOB: ID Number: Group Number: Secondary Insurance: Insured: Relationship to Patient: ID Number: Group Number: Patient Pharmacy Information: Pharmacy Name: Pharmacy Phone Number: Location (City, State): Pharmacy Fax Number:

5 Medical History Questionnaire Name: Date: / / Birth Date: / / Last Medical Exam: / / Name of Medical Doctor: Dr. s Phone: Name of Pharmacy and Location: Pharmacy Number: Last Eye Exam: / / Name of Eye Care Provider: Past Eye/Medical History Allergies: ne : (list) Have you ever had any eye injuries? : (list) Do you have any eye diseases? Please check all that apply. Macular Degeneration Cataract Glaucoma Diabetic Retinopathy Dry Eye Syndrome Other: (list) Have you ever had any eye surgeries? : (list) Do you currently use any eye medications? : (list) Do you have any medical conditions? Please check all that apply. Diabetes High Blood Pressure Heart Disease High Cholesterol Thyroid Disorder Autoimmune Disease (name: ) Please list any additional medical conditions. List all major surgeries: List all medications: Are you pregnant or nursing? Check if you have ever been exposed to or infected with: Gonorrhea Syphilis HIV Hepatitis TB Do you wear glasses? If yes, how old is your present pair of lenses? Do you wear contact lenses? If yes, how old is your present pair of lenses? Type of contact lenses: Rigid Soft Extended Wear Other Family History: (Check all that apply to your blood relatives) Diabetes Stroke Blindness Macular Degeneration Arthritis Cancer TB Cataracts Retinal Disease Lazy Eye Heart Disease Kidney Disease Glaucoma High Blood Pressure Other: Social History: Smoking Status: (Check one) Current every day smoker Current some day smoker Former smoker Never smoked Smoker, current status unknown Unknown if ever smoked If smoker: How much? How long? When quit? Alcohol Use: : Type? How much? Drugs: : Type? How much? How long? When quit? *Please turn this form over and complete side two*

6 Review of Systems: Please comment on any answers in the space provided below. Eyes Previous Surgery Contact Lens Use Pain Double Vision Glaucoma Cataracts Macular Degeneration Dry Eyes Flashes Floaters Ear, se and Throat Hard of Hearing Ringing in Ears Vertigo Cardiovascular Chest Pain Dizziness Fainting Spells Shortness of Breath Irregular Heart Beat Difficulty Lying Flat Constitutional Fatigue/Weakness Fever Weight Gain/Loss Jaw Pain When Chewing Scalp Tenderness Respiratory Cough Congestion Wheezing Asthma Gastrointestinal Heartburn Nausea/Vomiting Jaundice/Hepatitis Genito-Urinary Pain/Difficulty Urinating Blood in Urine History of Kidney Stones History of STD s Psychiatric Anxiety/Depression Mood Swings Difficulty Sleeping Endocrine Increased Thirst Increased Hunger Increased Urination Increased Sweating Fingernail Changes Blood/Lymphnodes Easy Bruising Gums Bleed Easily Prolonged Bleeding Heavy Aspirin Use MusculoSkeletal Stiffness Arthritis Joint Pain/Swelling Skin Rash/Sores Lesions Hives/Eczema Neurological Seizures Weakness/Paralysis Numbness Tremors Immunologic Hives Itching Runny se Sinus Pressure V1.4 Explanations: Doctor s Signature Review Date

7 Consent for Care Patient's Name: Date: I authorize and agree to the sharing of clinical care and communication between my primary care eye care provider and Eye Health Partners and/or its independent contractor doctors. I understand and agree that as a referral network, clinical and post-operative care will be coordinated between the doctors, using prudent and sound medical judgement, with the protection and preservation of my ocular health always the highest priority. I request that payment of authorized Medicare benefits, or any other third party payor, be made to me or on my behalf to Eye Health Partners of Middle Tennessee, Inc. and/or its independent contractor doctors for any services furnished me by that provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or any third party payors any information needed to determine these benefits or the benefits payable for related services. Signature of Patient: Witness Signature:

8 HIPAA Privacy Authorization/Acknowledgement Form **Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts (160 and 164) ** Patient's Name: Date: **1. Authorization** I authorize Eye Health Partners to use and disclose the protected health information described below to: 1), 2) 3), 4) (individual(s) seeking the information) [ ] one **2. Effective Period** This authorization for release of information covers the period of healthcare from: [ ] to **OR** [ ] All past, present, and future periods. **3. Extent of Authorization** [ ] I authorize the release of my complete health record (including records relating to mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse). **OR** [ ] I authorize the release of my complete health record with the exception of the following information: [ ] Mental health records [ ] Communicable diseases (including HIV and AIDS) [ ] Alcohol/drug abuse treatment [ ] Other (please specify): 4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. 5. This authorization shall be in force and effect until: [ ] (date or event), at which time this authorization expires. [ ] indefinite

9 6. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 7. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. 8. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Acknowledgement of Privacy Policy and Practices I understand that in an attempt to protect the privacy of my identifiable health information, Eye Health Partners of Middle Tennessee, Inc (EHP) has established a Privacy Policy and guidelines for Privacy Practices within our offices. This information details the use and or/disclosure of information contained in my personal medical/optometric records kept for the purposes of diagnosis, treatment, payment and health care options. In accordance with HIPAA Regulations, a copy of the EHP Privacy Policy and Practices has been made available to me. Should I choose to have a personal copy, one will be given to me at no charge. [ ] I have read, understand and acknowledge the Privacy Policy and Practices of EHP. [ ] I have elected not to read the Privacy Policy and Practices of EHP. [ ] A copy of the EHP Privacy Policy and Practices was made available to me. Please answer the following questions: 1) May we contact you at work? [ ] [ ] 2) May we leave messages for you on your voic or answering machine? [ ] [ ] Signature of patient or personal representative: Printed name of patient or personal representative and his or her relationship to patient: Date