RETINA ASSOCIATES OF SARASOTA John Niffenegger, MD Elizabeth Richter, MD, PhD Keye Wong, MD 3920 Bee Ridge Road, Bldg. D 1370 E. Venice Ave., Suite 201 1509 53rd Ave. West 3280 Tamiami Trail, Suite 41 Sarasota, FL 34233 Venice, FL 34285 Bradenton, FL 34207 Port Charlotte, FL 33952 (941) 924-0303 (941) 412-0303 (941) 924-0303 (941) 743-3937 FAX (941) 924-0309 FAX (941) 412-0309 FAX (941) 924-0309 FAX (941) 623-0309 Dear Patient, We would like to welcome you as a patient to Retina Associates of Sarasota. Your appointment will be scheduled with one of our doctors: Dr. John H. Niffenegger/ Dr. Keye L. Wong/ Dr. Beth Richter at your preferred location. To expedite your visit please help us by completing the following forms and present these to the receptionist upon your arrival: Patient Information Form Patient Financial Form Past Medical History and Review of Systems Form HIPPA Compliance Notification Form Please bring your insurance cards and photo identification. If you wear glasses bring your current pair. Dr. Niffenegger/ Dr. Wong/ Dr. Richter will usually see you within one hour of your scheduled appointment and would prefer a family member be present (a driver) since your eyes will be dilated.
PATIENT INFORMATION FORM Date: Referring Physician: Phone # Primary Care Physician: Phone # Patient Name: First MI Last Local Address: City: State: Zip: Local Phone: Cell Phone: Social Security# Sex: M F Date of Birth: Marital Status: Married_Single_Divorced_Widow_ Race: Ethnicity: Preferred Language: Email Address: Out of State Address: City/State/Zip: Phone Number: Emergency Contact: Relationship: Name Phone # Employer: Employer Phone # Employer Address: Preferred Pharmacy: Phone # INSURANCE INFORMATION Primary Insurance: Insurance Name: Policy # Group # Insured s Employer: Policy Holder Name: Relationship to Patient: Policy Holder Date of Birth: Policy Holder SS #: Insurance Address: Ins Phone # Secondary Insurance: Insurance Name: Policy # Group # Insured s Employer: Policy Holder Name: Relationship to Patient: Policy Holder Date of Birth: Policy Holder SS #: Insurance Address: Ins Phone # PLEASE PRESENT INSURANCE CARDS TO FRONT DESK AND BRING LIST OF MEDICATIONS
Patient Financial Policy Retina Associates of Sarasota PA is dedicated to providing the best possible care for you. Please understand that payment for services is considered part of your treatment. We ask that you read, agree to, and sign this policy prior to any treatment. Co-pays and balances The patient is expected to present a valid insurance card at each visit. All co-payments and patient balances are due at the time of service unless arrangements have been made in advance. We accept cash, check, and credit card. A $10.00 service charge is added to account when the co-pay is not paid at the time of service. A fee of $35.00 will be charged to you on checks returned by your bank for Non-Sufficient-Funds (NSF). Participating Insurance Plans Your insurance policy is a contract between you and your insurance company. As a service to you, we will file your insurance claim. If your insurance company does not pay the practice within a reasonable period, we will look to you for payment. If we later receive a payment from your insurer, we will refund any overpayment to you. We will bill your insurance company for all services provided by Retina Associates of Sarasota. You are responsible for any balance due. Not all insurance companies cover all services. In the event your insurance plan determines a service to be not covered, you will be responsible for the complete charges. Payment is due upon receipt of a statement from our office. Refraction charges are not covered by insurance and will be collected at time of service. Insurance Changes If you fail to notify us of an insurance change, you are fully responsible for any amount not paid by your insurance. Referrals If your insurance has a designated primary care physician (PCP) you are required to have prior authorization from your PCP prior to your office visit in order to receive maximum benefits. If an authorization/referral is not provided at the time of service, you will be asked to either reschedule your appointment or pay for your visit at the time of service. Self-pay Accounts Payment is required at the time of service for all services. Self-pay accounts are: - Patients without insurance information on file. - Patients without an insurance card at the time of service. - Patients who are covered by an insurance plan that the practice does not participate in. Non-participating Insurance Plans The financial obligations of patients who are insured by carriers that the practice does not participate with are considered a self-pay account. If you are insured by a plan that we do not have a prior arrangement with, as a courtesy we will prepare a claim for you on an unassigned basis. This means the insurer will send the payment directly to you. Therefore, our charges for your care are due at the time of service. For surgical procedures, please ask to speak to a billing representative prior to the procedure. I have read and understand the practice s financial policy and I agree to be bound by its terms. Signature of patient (or responsible party, if minor) Date Patient Name
Notice of Privacy Practice THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT HOW YOU MAY BE USED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Health Insurance Portability & Accountability Act of 1996 { HIPPA } is a federal program that requires that all medical records and other individually identifiable Health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This act gives you, the patient, significant new rights to understand and control how your health information is used, HIPPA provides penalties for covered entities that misuse personal health information. As required by HIPPA we have prepared this explanation of how we are required to maintain the privacy of your health care operations. We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations. Treatment means providing, coordinating, or managing health care and related series by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending your bill for your visit to your insurance company for payment. Healthcare operations include the business aspect of running a practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis and customer service. An example of this would be an internal quality assessment review. We may also create and distribute de-indentified health information by removing all referent to individually identifiable information. We may contact you to provide appointment reminders for information about treatment alternatives or other health related benefits and services that may be of interest to you. Any other uses and disclosers will be made only with your written authorization. You may revoke such authorization in writing and we are required to abide by that written request, except to the extent that we have already taken action relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosers of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information form use by alternative means or at alternative locations. The right to inspect and copy your protected health information. The right to amend our protected health information. The right to receive an accounting of disclosure of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of December 21, 2007 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provision effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that privacy protections have been violated. You have the right to file written complaints with our complaint officer or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint. Please contact us for more information or to file a complaint. Patient Signature Date
PATIENT NAME DATE OF BIRTH M_ F_ DIABETES (TYPE I/TYPE II) YR OF ONSET Blood Sugar AIC Eyes Involved R L CATARACTS SURGURY Right Left DRY EYES HIGH BLOOD PRESSURE ARTHRITIS ASTHMA/ CHRONIC PULMONARY DISEASE CANCER (Location: / Treatment: ) CARDIAC DISEASE/HEART ATTACK CROHN S/INFLAMMATORY BOWEL DISEASE DEMENTIA/ALZHEIMER S DISEASE GRAVES DISEASE/THYROID DISEASE HEADACHES HIGH CHOLESTEROL HIV/ AIDS KIDNEY DISEASE LIVER DISEASE/HEPATITIS MULTIPLE SCLEROSIS PEPTIC ULCER DISEASE STROKE FLU SHOT Date: PNEUMONIA SHOT OTHER: PREVIOUS SURGERIES FAMILY OCULAR HISTORY CARDIAC/ CAROTID BLINDNESS EYE (RIGHT/ LEFT) CATARACTS GLAUCOMA RETINA MACULAR DEGENERATION OTHER RETINAL DETATCHMENT NEUROSURGERY OTHER OTHER MEDICATIONS (Include over the counter medications or ATTACH YOUR LIST OF MEDICATIONS) SOCIAL HISTORY ALLERGIES TO MEDICATIONS Y N (REACTION) SMOKER (NEVER/ FORMER/ CURRENT) ALCOHOL HOW OFTEN SUBSTANCE ABUSE OTHER: WHAT MARTIAL STATUS: OCCUPATION: DO YOU HAVE DIFFICULTIES WITH? EYES IMMUNOLOGY CARDIOVASCULAR FEVER WEIGHTLOSS STOMACH/ GI KIDNEYS HEMATOLOGY /BLOOD HEARING EAR/ NOSE/ THROAT SKIN MUSCLES/ BONES NEURO/ HEADACHES PSYCHIATRIC COUGH BREATHING OTHER: