Lakeview Eye Care Eye Medicine and Surgery Christine C. Platt, M.D. Chad Lehtonen, O.D. One Lakeview Park Rochester, New York 14613 NOTICE OF PATIENT FINANCIAL RESPONSIBILITY At Lakeview Eyecare, we are dedicated to giving exceptional care and to helping patients understand and manage their medical expenses. INSURED PATIENTS: If you have insurance, you must bring your insurance card with you to each appointment. You are responsible for reviewing your insurance company's guidelines for fees, deductible amounts and copays, especially for specialists. If you have a deductible, high capay, or percentage copay, we will assist you by :filingclaims in a timely fashion. Once the claim is processed, you may have a balance due for services rendered and you are responsible for paying this amount. If you fail to provide us with correct insurance information in time to meet your insurance company's filing deadline, you will be responsible for the entire balance of the bill COPAYMENTS: Your insurance company requires that all copayments for services and procedures must be made at the time of the appointment. Failure to render the copay will result in a $20.00 administrative fee. Late fees will accrue on overdue bills, and after we make a concerted effort to collect payment, we shall refer the account to a collection agency. Expenses incurred for collection will be your responsibility. If you have no health insurance, we expect payment at the time service is rendered. However, we recognize extenuating circumstances and may accept partial payment and a payment plan to meet this obligation. All balances are due within 90 days. CANCELLATIONS: A fee of $50 will be charged for missed appointments unless you notify us of a cancellation at least 24 hours in advance. Repeated missed or cancelled appointments will result in discharge from the practice. If you have an outstanding balance and have not made arrangements to pay your bill, no new appointments will be scheduled. Patient's Signature. Date. _
Christine C. Platt, M.D. Lakeview Eye Care One Lakeview Park Rochester, New York 14613 Ophthalmology USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION In accordance with Federal HIP AA regulations, LAKEVIEW EYE CARE may use and disclose my protected health information (PHI) to carry out treatment, payment and healthcare operations (TPO). Lakeview Eye Care may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including surgery, laboratory and clinical tests, consultations among others. Lakeview Eye Care may mail to my home or other designated location, any items that assist the practice in carrying out TPO, such as appointment reminder cards, patient statements, information pertaining to scheduled surgery or laser, etc. as long as they are marked 'Personal and Confidential'. I have the right to request that Lakeview Eyecare restrict how it uses or discloses my PHI to carry out my TPO: You may release/discuss my PHI with the following individuals: Name Relationship Name. ~_Relationship _ Please refer to the Lakeview Eye Care Notice of Privacy Practices for a more complete description of such uses and disclosures. A copy of Lakeview Eye Care's Notice of Privacy Practices has been made available for my review. Signature of patient (or representative w/relationship) Date
Lakeview Eye Care, Cnrtstme C. Platt, M.D. Chad Lehtonen, O.D. Eye Meclicine and Surgery, One Lakeview Park 2 Rochester, New York 14613 HIPAA MEDICAL RECORDS RELEASE I, _---:::-:~~~~--- Print Name of Patient Date of Birth Street Address City, State, Zip Code authorize the release of my medical records from: Name of Physician Address To: Christine C. Platt, M.D. / Chad Lehtonen, O.D. at Lakeview Eye Care Information to be released: Office Notes Correspondence Photographs Test Reports Visual Fields Other I do not: do: want HIV or AIDS related information released. 1 understand that this authorization shall be valid for one (1) year unless otherwise stated below or revoked through written notice. Alternate date, if not one year: _ I authorize release of my medical records in accordance with the specifications listed above. I understand written notice is necessary to cancel this request. Signature of Patient Date. _ OR, if Patient is: Minor --- Incompetent Disabled Deceased Authorized Signature Relationship
MEDICAL HISTORY: NAME: DATE:...2..-_ List all MAJOR ILLNESSES (glaucoma, diabetes, high blood pressure, heart attack, stroke, cancer, etc.) List any SURGERIES that you have had (cataract, tonsillectomy, appendectomy, etc.): Please list any EYE MEDICATIONS that you currently use: _ ~------------------------------------- SOCIAL HISTORY: YES NO Do you wear GLASSES? Do you or have you ever worn CONTACT LENSES? Do you DRIVE? Do you have problems with NIGHT VISION? Do you SMOKE? Occasionally Yz pack /day: 1 pack /day: 1+ pack /day: Do you drink ALCOHOL? Occasionally l/day 2-3/day 4+ /day Have you ever had a BLOOD TRANSFUSION? Are you PREGNANT or have you given birth in the past 6 months? Do YOU currently have any problems in the following areas? If YES please provide information. - PATIENT HISTORY: ;YES YES NO EXPLANATION OF PROBLEM LOSS OF VISION BLURRED VISION FLUCTUATING VISION DISTORTED VISION (HALOS) DOUBLE VISION REDNESS DRYNESS OR BURNING ITCHING MUCOUS DISCHARGE EXCESS TEARING / WATERING FLASHES OF LIGHT FLOATERS CROSSED EYES, LAZY EYE GLARE / LIGHT SENSITIVITY EYE PAIN INFECTION OF EYE OR LID (STYE) (PLEASE COMPLETE THE OTHER SIDE OF THIS FORM)
(Patient history continued): GENERAL YES NO EXPLANATION ON PROBLEM FEVER WEIGHT LOSS OTHER: SYSTEMS YES NO EXPLANATION OF PROBLEM EARS, NOSE, THROAT, (Sinus, chronic cough, dry mouth, etc.) CARDIOV ASCULAR (heart, vessels, etc.) RESPIRATORY (asthma, emphysema, etc.) G.!. DISEASE (ulcers, intestinal dis., etc.) KIDNEY, BLADDER, GENITAL MUSCLES,BONES,JOINTS (arthritis, etc.) SKIN (acne, skin cancer, etc.) NEUROLOGICAL (multiple sclerosis, etc.) PSYCHIATRIC (anxiety, depression, etc.) ENDOCRINE (diabetes, hypothyroid, etc.) BLOOD (cholesterol, anemia, etc) ALLERGIES (hay fever, etc.) IMMUNOLOGIC (lupus, Sjogrens, etc.) Which blood relatives in your FAMILY have a history of any ofthe following? FAMILY HISTORY: YES NO RELATIONSHIP TO PATIENT BLINDNESS GLAUCOMA MACULAR DEGENERATION LAZY EYE DIABETES HEART DISEASE HIGH BLOOD PRESSURE CANCER THYROID DISEASE STROKE OTHER: (Medications and drug allergies WIll be reviewed WIth you and will be hsted on a separate sheet) Patient's Signature: ~ _ Date: ----- Physician's Signature: _ Date: _