We Kids and Teens! Welcome to Our Office This information will allow us to serve the child and parents or guardians best. Thank you for your help. Patient s Name Last First Middle Nickname or Preferred Address Street or P.O. Box City State Zip Patient s Date of Birth / / Age SS# - - Sex M F Father s Name Where employed? Work Phone Father s Date of Birth / / SS# - - Insurance Co. Address (if different from above) Mother s Name Where employed? Work Phone Mother s Date of Birth / / SS# - - Insurance Co. Address (if different from above) In the event of an emergency, contact _ Relation _ Phone - Employer If student, grade level School Teacher Is anyone else in the family a patient here? How will you be paying today? Full payment by cash, check, or credit card Vision Care insurance with deductible/co-pay Polycarbonate lenses are the most impact resistant lenses available and are the safest for children and/or sports. Your Initials I request that payment of benefits be made to me or the doctor for any services provided. I also authorize any holder of medical information about me to release to the carrier and its agents any information needed to determine these benefits or the benefits payable for related services. signature date Thank You.
Medical History Questionnaire Name: Date: / / Birth Date: / / Last Medical Exam: / / Last Eye Exam / / Name of Medical Doctor: Dr. s Phone: Medical History Do you have any allergies to medications? no yes If yes, explain: List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): 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 Do you wear contact lenses? no yes If yes, how old is your present pair of lenses? Type of contact lenses: Rigid Soft Extended Wear Other Are they comfortable? no yes Family History Please note any family history (parents, grandparents, siblings and/or children, living or deceased) for the following medical 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 Kidney Disease Lupus Thyroid Disease Other Social History 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? Have you ever been exposed to or infected with: Gonorrhea Syphilis HIV Hepatitis *Page 1 of 2*
Review of Systems Do you currently, or have you ever had any problems in the following areas: (If YES, please explain and list medications) System NO YES? EXPLAIN / MEDICATIONS INTEGUMENTARY (Skin) NEUROLOGIC Headaches Migraines Seizures EYES Loss of Vision Blurred Vision Distorted Vision / Halos Loss of Side Vision Double Vision Dryness Mucous Discharge Redness Sandy or Gritty Feeling Itching Burning Foreign Body Sensation Excess Tearing / Watering Glare / Light Sensitivity Eye Pain or Soreness Chronic Infection of Eye or Lid Styes or Chalazion Flashes / Floaters in Vision Tired Eyes EARS, NOSE, MOUTH, THROAT Allergies Hay Fever Sinus Congestion Runny Nose Post-Nasal Drip Chronic Cough Dry Throat / Mouth RESPIRATORY Asthma Chronic Bronchitis Emphysema VASCULAR Diabetes Heart Pain High Blood Pressure Vascular Disease GASTROINTESTINAL Diarrhea Constipation GENITOURINARY (genitals / kidney / bladder) BONES / JOINTS / MUSCLES Rheumatoid Arthritis Muscle Pain Joint Pain LYMPHATIC / HEMATOLOGIC Anemia Bleeding Problems ENDOCRINE (thyroid / other glands) PSYCHIATRIC Doctor s Signature _ Review Date *Page 2 of 2*
Toomey & Baggett Eyecare Clinic, PLLC 406 W. Madison Ave. Athens, TN 37303 (423) 746-9988 Fax (423) 746-9984 Jean Ann Toomey, O.D. J. Dean Baggett, O.D. CONSENT TO TREAT Patient Name: Date of Birth / / By signing this form, I consent to treatment for myself and/or on behalf of the Minor for which this information pertains. I give permission for the doctor/s to examine, diagnose and initiate treatment as deemed appropriate. I further, attest that I am the Parent or Legal Guardian of the Minor and have the authority to authorize care and treatment. Patient/Parent or Guardian Today s Date Doctor s Signature Review Date
Toomey & Baggett Eyecare Clinic, PLLC 406 W. Madison Ave. Athens, TN 37303 (423) 746-9988 Fax (423) 746-9984 Contact Person: Ashley Brady, HIPAA Coordinator ACKNOWLEDGEMENT OF PRIVACY POLICY AND PRACTICES I understand that in an attempt to protect the privacy of my identifiable health information, Toomey & Baggett Eyecare Clinic, PLLC has established a Privacy Policy and guidelines for Privacy Practices within their office(s). 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 operations. In accordance with HIPAA Regulations, a copy of the Toomey & Baggett Eyecare Clinic, PLLC Privacy Policy & Practices has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge. [ ] A copy of the Toomey & Baggett Eyecare Clinic, PLLC Privacy Policy & Practices was given to me today. [ ] A copy of the Toomey & Baggett Eyecare Clinic, PLLC Financial Policy was given to me today. In the event a family member requests information regarding you or your account may we release this information? [ ] YES (list below) [ ] NO Name Relationship Name Relationship Consent For Use Or Disclosures Of Health Information Our Privacy Pledge We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information. There are several circumstances in which we may have to use or disclose your health care information. We may have to disclose your health information to another health care provider or a hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition. We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services. We may need to use your health information within our practice for quality control or other operational purposes. APPOINTMENTMENT REMINDERS AND HEALTH CARE INFORMATION AUTHORIZATION Your optometrist and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you with appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. If this contact is made by phone and you are not at home or at work, a message will be left on your answering machine. By signing this form, you are giving us authorization to contact you with these reminders and information. I authorize you to use or disclose my health information in the manner described above. I am also acknowledging that I have received a copy of this authorization. Your Right to Revoke Your Authorization You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. I have read your consent policy and agree to its terms. I am also acknowledging that I have received a copy of this notice. Patient Name (Printed) Patient Signature Personal Representative (Printed) Date Authorized Provider Representative Personal Representative Signature Description of Personal Representative s Authority to Act for the Patient
Toomey & Baggett Eyecare Clinic, PLLC 406 W. Madison Ave. Athens, TN 37303 (423) 746-9988 Fax (423) 746-9984 FINANCIAL POLICY STATEMENT We would like to thank you for choosing Toomey & Baggett Eyecare Clinic, PLLC and allowing us to provide your healthcare needs. The policies listed herein have been approved by the management with the goal of providing the finest care and service to our patients at the least cost. Care delivered by this facility will be administered regardless of race, color, creed, social status, national origin, handicap or sex. We are committed to providing you with the best possible care. In order to accomplish this, we need your assistance in reading and understanding financial responsibility and our payment policy. RESPONSIBILITY FOR THE BILL It is the expectation that all patients/guarantors receiving services are financially responsible for the timely payment of all charges incurred. While we will file verified insurance for payment of the bill(s) as a courtesy to the patient, the patient/guarantor is ultimately responsible for payment and agrees to pay the account(s) in accordance with the regular rates and terms of the clinic in effect at the present time. POINT OF SERVICE COLLECTIONS Payment for service is due at the time the service is rendered and non-emergency services may be deferred until the necessary payment arrangements have been accomplished. Payment will be accepted in cash, checks, Master Card, Visa or American Express. We will be happy to file verified insurance on your behalf. ACCEPTANCE OF INSURANCE The clinic will accept Assignment of Benefits on verified insurance policies and submit a bill to the carrier on the patient s behalf. It is understood that insurance is filed as a courtesy to the patient and does not relieve the patient of financial responsibility. Claims filed will be held 45 days pending payment. The patient/guarantor will be responsible for payment in full on all claims not paid within the allowed period of time. PATIENT RESPONSIBILITY Balances after insurance are due within 30 days of the insurance payment, unless other satisfactory arrangements have been made with the clinic. A service charge of 1.50% per month will be added after 60 days. This is an APR of 18.00%. There is a minimum service charge of $1.50. Not all services are covered by all insurance companies. It should be understood that by accepting the services(s), the patient is responsible for payment regardless of the fact that insurance covers the service or not. OPTICAL DISPENSARY We request that at least one-half of the balance of materials obtained in our optical dispensary be paid for when the order is placed. The balance must be paid at the time the materials are dispensed to the patient. CONTACT LENSES Our office charges a reasonable fee for evaluation and fitting of contact lenses. These fees are due and payable at the time the services are provided. The fee for contact lenses is due and payable when the contacts are dispensed to the patient. The Administration and Management welcomes the opportunity to discuss any aspect of the financial policy. We appreciate your confidence and strive to provide quality healthcare.