--Cen lral Piedmon l Retina Practice Limited to the Diseases of the Retina and Vitreous 3333 Brookview Hills Blvd., Suite 201 Winston-Salem, NC 27103 Telephone: (336) 602-2801 Fax:(336)602-2804 Name: Appointment Date: Date: Time: PLEASE COMPLETE THE ENCLOSED MEDICAL HISTORY QUESTIONNAIRE AND PATIENT INFORMATION FORMS: BRING A LIST OF ALL MEDICATIONS AND EYE DROPS YOU ARE CURRENTLY USING OR TAKING. BRING YOUR INSURANCE CARDS. MAKE SURE ALL REFERRALS ARE CURRENT IF REQUIRED. RETURN ALL INFORMATION IN THE SELF-ADDRESSED, STAMPED ENVELOPE OR BRING THE COMPLETED INFORMATION WITH YOU AT YOUR SCHEDULED APPOINTMENT. IMPORTANT YOUR EYES WILL BE DILATED. THIS WILL CAUSE YOUR VISION TO BE BLURRY. PLEASE BRING A DESIGNATED DRIVER. PLEASE ALLOW AT LEAST 2 HOURS FOR YOUR APPOINTMENT. THANK YOU, CENTRAL PIEDMONT RETINA, PA
1 ----==--- Cen lr'al Piedmon l Retina Practice Limited to the Diseases of the Retina and Vitreous 3333 Brookview Hills Blvd., Suite 201 Winston-Salem, NC 27103 Telephone: (336) 602-2801 Fax: (336) 602-2804 NEW PATIENT HISTORY INFORMATION FORM Patient's Name: Date of Birth: Social Security#: Today's Date: Patient ID#: Referring Physician: Address: City: Home Phone: Work Phone:---------- Emergency Contact: State: Zip Code: Mobile/Cell: Other: Relationship Emergency Contact Telephone#: WHEN YOU PROVIDE YOUR WIRELESS TELEPHONE OR LAND LINE NUMBER, YOU ARE GIVING US YOUR CONSENT TO CALL THAT NUMBER. Check one: Married Divorced Separated Widowed I Single Employed Retired Student Unemplpyed Employer: Employer Phone: EmployerAddress: over
NEW PATIENT HISTORY INFORMATION FORM (CONT.} Primary Insurance Company: Insured Name: Policy#: Insured Social Security#: Relationship to Patient: Insured Birthdate: Employer: Work Phone#: Other Insurance: ----------------------------- Company: Policy#: Group# Please allow us to photocopy your insurance card INSURANCE INFORMATION: Payment for services rendered is to be made as follows: I request that payment of authorized insurance benefits be made to Central Piedmont Retina. This practice is limited to the treatment for the disease of the retina and vitreous. I authorize payment for any services, medications and/or medical supplies provided in my treatment. I authorize Central Piedmont Retina to release to the Health Care Financing Administration (HCFA/CMMS), my insurance Carrier and/or its agent's appropriate information needed to determine these benefits or the benefits payable for related services, in accordance with the HIPPA guidelines. I am financially responsible for appropriate deductibles, copayments, and non-covered items (this information has been supplied to me by my carrier). If this account is delinquent for non-payment, the account may be turned over to a collection agency. I will be responsible for all costs of collection including the court costs and reasonable attorney fees. Date Signed x Patient or Responsible Party Signature I Relationship to Patient
-- -- Cen lr'al Piedmon l Retina Patient Name (print) Medicare Number Signature on File, Assignment of Benefits, Financial Agreement 1. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Central Piedmont Retina. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information nec essary to pay the claim. If other health insurance is indicated in Item 9 of the CMS-1500 form or elsewhere on other approved claim forms, my signature authoriz es releasing the information to the insurer or agency shown. Central Piedmont Retina. Charge determination of the Medicare carrier as the full charge, and I am respon sible only for the deductible, coinsurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier. 2. MEDIGAP: I understand that if a MediGap policy or other health insurance is indi cated in Item 9 of the Form-1500/(0212) or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Central Piedmont Retina if possible, or otherwise to me. 3. RELEASE OF INFORMATION: Central Piedmont Retina may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corpo ration (1) which is or may be liable or under contract to Central Piedmont Retina for reim bursement for services rendered, and (2) any health care provider for continued patient care. Central Piedmont Retina may also disclose on an anonymous basis any informa tion concerning my case, which is necessary or appropriate for the advancement of medical science, medical education, medical research, for the collection of statistical data or pursuant to State or Federal law, statute or regulation. A copy of this authori zation may be used in place of the original.
4. OTHER INSURANCE: I understand that Central Piedmont Retina maintains a list of health care service plans with which it contracts. The undersigned agrees that I am individu ally obligated to pay the full charges of all services rendered to me by Central Piedmont Retina if I belong to a plan that does not appear on the above mentioned list. 5. NON-COVERED SERVICES: I understand that Central Piedmont Retina contracts with health care service plans (i.e., HMOs, PPOs) relate only to items and services which are covered by the health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services which are determined by the health care service plans not to be covered. Examples of noncovered services include, but are not limited to, services not specified as being covered in the patient's contract with a health care service plan or in the benefit summary the health care service plan furnished to the patient, and treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with Central Piedmont Retina to obtain necessary health care service plan authorizations. 6. FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Central Piedmont Retina, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Central Piedmont Retina for payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney's fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefit of any type under any policy of insurance insur ing the patient, or any other party liable to the patient, is hereby assigned to Central Piedmont Retina. If co-payments and/or deductibles are designated by my insurance com pany or health plan, I agree to pay them to Central Piedmont Retina. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill. Patient Signature or Authorized Party Date Relationship