COLUMBIADOCTORS OPHTHALMOLOGY Edward S. Harkness Eye Institute - 635 W. 165 th Street, New York, NY 10032 880 3 rd Avenue 2 nd Floor, New York, NY 10022 Morgan Stanley Children s Hospital of New York 3959 Broadway, 5 th Floor, New York, NY 10032 15 W. 65 th Street, New York, NY 10023 119 Prospect Street Suite#1, Ridgewood, NJ 07450 PATIENT REGISTRATION INFORMATION Date: MR#: Date of Birth: Age: Last Name: First Name: Middle Initial: Gender: Male Female Address: Apt#: City: State: Zip Code: Home Phone: Cell Phone: Email: Marital Status (circle one): Single/Married/Div./Sep./Widowed Spouse s Name (if applicable): Mother s First Name: Father s First Name: Employer: Occupation: Business Address: Business Phone: Primary Care Physician: Phone: Address: Pharmacy Address: Phone: Referred by: In case of emergency, who should we contact? Phone: Workman s Compensation: No Fault: PRIMARY INSURANCE: Person responsible for account: Phone: Relationship to Patient: Date of Birth: Address (if different from patient): Ins. Company: Ins. Company Address: Subscriber ID#: Group #: Co-pay: $ ADDITIONAL INSURANCE: Person responsible for account: Phone: Relationship to Patient: Date of Birth: Address (if different from patient): Ins. Company: Ins. Company Address: Subscriber ID#: Group #: Co-pay: $ Signature of Responsible Party: Date:
MEDICAL INFORMATION SHEET NAME: Chief Complaint: What is the main or primary problem with your eye(s), and when did you first notice symptoms or were you told of diagnosis? Past History: Do you have or have you had any of the following problems or conditions? Please answer ALL questions - Indicate YES or NO. If the answer is YES, provide a brief explanation. EYES Glaucoma YES NO Cataract YES NO Lazy Eye (Amblyopia) YES NO Crossed Eyes (Strabismus) YES NO Macular Degeneration YES NO Retinal Detachment YES NO Eye Injury YES NO Eye Inflammation YES NO Laser Surgery YES NO Operative Surgery YES NO GENERAL HEALTH Fevers YES NO Weight Loss YES NO Fatigue YES NO Sinusitis / Nasal Allergies YES NO Hearing Loss YES NO Dry Mouth YES NO Angina / Chest Pain YES NO Heart Attack YES NO Congestive Heart Disease YES NO Rheumatic Heart Disease YES NO Heart Murmur YES NO Irregular or Slow Heartbeat YES NO High Blood Pressure YES NO Stroke YES NO Shortness of Breath YES NO Asthma YES NO Bronchitis YES NO Emphysema YES NO Heartburn / Ulcer YES NO Hepatitis YES NO Liver Disease YES NO Kidney Disease YES NO Kidney Stones YES NO EXPLANATION
Past History: Do you have or have you had any of the following problems or conditions? Please answer ALL questions - Indicate YES or NO. If the answer is YES, provide a brief explanation. General Health (cont) Eczema / Rash YES NO Skin Cancer / Moles Removed YES NO Mouth Ulcers YES NO Arthritis YES NO Rheumatologic Condition (ie:lupus) YES NO Arm or Leg Weakness or Numbness YES NO Multiple Sclerosis YES NO Psychiatric Condition YES NO Depression YES NO Anxiety YES NO Anemia YES NO Sickle Cell Disease YES NO Easy Bruising / Bleeding YES NO Blood Clotting Disorder YES NO Diabetes YES NO Thyroid Condition YES NO Cancer YES NO Are you or could you be pregnant? YES NO Do you drink? How much? YES NO Do you smoke? How much? YES NO Do you drive? YES NO Are you allergic to any medications / dyes? YES NO EXPLANATION Do you take any medications (including YES NO drops)? If, possible indicate dosages. Have you had any previous surgery? YES NO Type? When? Should we be aware of any other matter Regarding your overall health? YES NO Patient Signature: Date: Doctor s Signature: Date:
COLUMBIADOCTORS OPHTHALMOLOGY AUTHORIZATION OF BENEFITS Name of Beneficiary: Health Insurance Claim #: I request that payment of authorized health insurance benefits, including Medicare and Medigap, be made either to me or on my behalf to Dr. for services furnished to me by this provider. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any information needed to determine these benefits payable for related services. Signature of Responsible Party: Date: Commercial Insurance I hereby authorize direct payment of surgical/medical benefits to Dr. for services rendered by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance not covered by my insurance, including co-pays, deductibles, refractions, and differences between surgeon s charges and allowable. I hereby authorize Dr. to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits. Signature of Responsible Party: Date: Advance notice regarding Insurance Reimbursement and Beneficiary Agreement I have been informed that refraction (the measurement of one s eyeglass prescription and the determination of the best visual sharpness) is usually not considered by insurance companies, health maintenance organizations, and Medicare to be medically reasonable of necessary. Knowing this, I have instructed the doctor to proceed with the services. If insurance decides to reduce or even deny the fee or services, I agree to pay the doctor s fee in full. Signature of Responsible Party: Date:
Health Insurance Portability and Accountability Act (HIPAA) HIPAA Compliance/Columbia University Medical Center 601 West 168 th Street, Apt. #22, 2 nd Floor New York, NY 10032/ T(212) 342-0059 F(212)342-5173 http://www.cumc.columbia.edu/hipaa/ NOTICE OF PRIVACY PRACTICES DATE: ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I was provided with a copy of the Columbia University Medical Center Notice of Privacy Practices. Patient Name (Print) Patient Signature If completed by a patient s personal representative, please print and sign your name in the space below Personal Representative (Print) Personal Representative s Signature Relationship For Columbia University Medical Center use only. Complete this section if this form is not signed and dated by the patient or patient s representative. I have made a good faith effort to obtain a written acknowledgement of receipt of Columbia University Medical Center s Notice of Privacy Practices but was unable to for the following reason: Patient refused to sign Patient unable to sign Other Employee Name Date This form should be placed in the patient s medical record Revised October 2007
ColumbiaDoctors Ophthalmology Refraction Fee Policy What is a refraction? Refraction is a test done to determine the refractive error of your eyes, or the need for corrective glasses and/or contact lenses. When do I have to pay for a refraction? Refraction (CPT code 92015) is a non covered service by Medicare. As a result, your healthcare provider is required by CMS (the department to the federal government that controls Medicare) to charge for this service. Most other insurance plans follow Medicare s rules. All these plans consider refraction a vision service not a medical service. How much do I have to pay? You will only be charged a refraction fee if you receive a prescription for glasses or contact lenses. Our office fee for refraction is $80. This is collected at the time of service in addition to any co payment your plan may require. Should your plan pay us for the refraction, we will refund you accordingly. Suggestions When Filling Your Prescription Since refraction (measuring for an eyeglass and/or contact lens prescription) is an inexact art in which errors may arise at any step, including from the patient, the doctor, and the optician making the eyeglasses, we suggest the following: 1. Fill your prescription at an establishment that agrees to make at least one adjustment (including changes that we make in the prescription if you are having trouble with new glasses) at no charge to you. 2. Purchase only one pair of new glasses with the new prescription, so that if any changes are made subsequently, only one pair of glasses need be adjusted. Once you are sure you are happy with the new prescription, proceed with making additional pairs as needed. 3. Please address any legibility issues regarding the written prescription with the prescribing doctor prior to filling the prescription. 4. Change as few parameters lens size and shape, lens company/brand (especially with progressive add spectacles) as possible with your new glasses to minimize the risk of being uncomfortable with newly prescribed glasses. What if my glasses or contact lenses don t fit well? Our physician will re evaluate you at no charge within 60 days of your initial refraction to change your prescription if necessary. However, our office does not pay for revision of glasses in which good faith efforts were made in measuring and writing the prescription.