New Patient Form (Already Registered? Click Here to update your patient information)


Title First Last MI Suffix Nickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SSN Email
Birthday Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Primary Doctor Misc/Guardian

Billing Information Is The Billing Address the Same?
Title First Last MI Suffix
Address

CityStateZipCode
Home Phone:
Work Phone:

Primary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Secondary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Tertiary

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name: Last, First MI
Relationship to Insured: Spouse Child Other
Sex: Male Female
Address:
City: State: Zip:
Phone Number:
Birthday:
Employer/School:

Medical History

Preferred language Race Ethnicity Height ft in Weight lbs

Date of last evaluation:
How did you learn about our office?
Are you Interested in Contact Lenses?
Yes No
Have you ever worn contact lenses?
Yes No
Contact Lens Wearers:
Are your lenses comfortable? Yes No
Current Brand:
What solution do you use?
What is your replacement schedule?
How old is your current pair?

SOCIAL HISTORY
This information is required by insurance carriers and is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer. If so, check here:
Smoking Status
Do you drink alcohol?
Yes No If yes, type/amount/how often:
Do you use illegal drugs?
Yes No If yes, type/amount/how often:
Are you currently or have you ever been infected with:
SET ALL TO NO
Tuberculosis
Yes No
Hepatitis
Yes No
HIV
Yes No
Syphilis
Yes No
Chlamydia
Yes No

Eyes
Do you experience any of the following?
SET ALL TO NO
Blurred Vision
Yes No
Burning
Yes No
Eyes feel dry
Yes No
Double Vision
Yes No
Eyes tear
Yes No
Eyes "hurt" or "tired"
Yes No
Flashes
Yes No
Floaters
Yes No
Foreign body sensation
Yes No
Eyes itch
Yes No
Bothered by light / sun light
Yes No
Halos around lights
Yes No
Redness
Yes No
Eyes feel sandy/gritty
Yes No
Mucous discharge
Yes No
Do you have a history of any of the following?
Blindness
Yes No
Eye Turn (Strabismus)
Yes No
Lazy Eye (Amblyopia)
Yes No
Patching
Yes No
Glaucoma
Yes No
Cataracts
Yes No
Macular Degeneration
Yes No
Retinal Detachment
Yes No
Eye Surgery
Yes No
Eye Injury
Yes No

MEDICAL HISTORY / REVIEW OF SYSTEMS:
Primary Care Physician: Last visit BP
Do you have any allergies to medications? Yes No If yes, please list:
Are you pregnant or nursing? Yes No N/A
Do you currently, or have you ever had, any problems in the following areas?
SET ALL TO NO
1- CONSTITUTIONAL:
Fever
Yes No
Weight Loss/ Gain
Yes No
Other
2- INTEGUMENTARY (SKIN):
Herpes Zoster (Shingles)
Yes No
Eczema
Yes No
Rosacea
Yes No
Other
3- NEUROLOGICAL:
Migraines
Yes No
Seizures
Yes No
Multiple Sclerosis
Yes No
Other
4- ENDOCRINE:
Thyroid problems
Yes No
Diabetes
Yes No
Other
5- ALLERGIC/ IMUNOLOGIC:
Drug Allergy
Yes No
Enviromental Allergy
Yes No
Lupus
Yes No
Other
6- RESPIRATORY:
Asthma
Yes No
Bronchitis
Yes No
Emphysema
Yes No
Other
7- EAR/ NOSE/ THROAT:
Allergies/Hay fever
Yes No
Chronic Cough
Yes No
Sinus Congestion
Yes No
Other
8- CARDIOVASCULAR:
Heart Disease
Yes No
High blood pressure
Yes No
Stroke
Yes No
Vascular Disease
Yes No
Other
9- GASTROINTESTINAL:
Crohn's
Yes No
Colitis
Yes No
Ulcer
Yes No
Other
10-GENITOURINARY:
Genital/ Kidney/ Bladder
Yes No
Other
11- MUSCULOSKELETAL:
Arthritis
Yes No
Fibromyalgia
Yes No
Muscular Dystrophy
Yes No
Other
12- HEMATOLOGIC/ LYMPHATIC:
Anemia
Yes No
Leukemia
Yes No
Bleeding Problems
Yes No
Other
13- PSYCHIATRIC:
Depression
Yes No
Panic Disorder
Yes No
Schizophrenia
Yes No
Other
List of your current medication:

FAMILY HISTORY Family history is unknown/adopted
SET ALL TO NO
Lazy Eye (Amblyopia)
Yes No Relationship To Patient
Blindness
Yes No Relationship To Patient
Cataracts
Yes No Relationship To Patient
Glaucoma
Yes No Relationship To Patient
Retinal Detachment/Disease
Yes No Relationship To Patient
Macular Degeneration
Yes No Relationship To Patient
High Blood Pressure
Yes No Relationship To Patient
Diabetes
Yes No Relationship To Patient

Signature Forms

View Patient Responsibility Disclosure Statement
* I have read and understand the Patient Responsibility Disclosure Statement.


View HIPAA Privacy Policies
* I have been given the opportunity to read this practice's HIPAA Privacy Policies.


Dr. Michael Brodsky & Associates, Inc.

Patient Financial Responsibility Disclosure Statement

Medical Insurance

We have contracts with many insurance companies. We will bill them as a service for you. As the Patient or Responsible Party, you are responsible for any balance if your insurance company refuses to pay for any reason. The person signing on behalf of the Patient as the Responsible Party must:

  • Inform Michael Brodsky & Associates, Inc. of the current address and/or phone number for the Patient and Responsible Party.
  • Present all current insurance cards (Vision and Medical) prior to each visit.
  • Pay any required co-pay at the time of the visit.
  • Pay any additional amount owing within 30 days of receiving a statement from our office.

Note: When our office receives an Explanation of Benefits (EOB) from your insurance company, any amounts that you need to pay will be billed to you.

I understand that EyeMed Insurance will not cover any ancillary testing such as Optomap and QuantifEYE and I will pay for these elective tests at the time of service.

Non-Payment on Account

Should Collection proceedings or other legal action become necessary to collect overdue amount, the Patient's Responsible Party should understand that Dr.Michael Brodsky & Associates has the right to disclose to an outside Collection Agency all relevant personal and account information necessary to collect payment for services rendered. The Patient, or patent's Responsible Party understands that they are responsible for all costs of collection. This will be added to the outstanding balance. By signing below, you agree to accept full financial responsibility as a Patient who is receiving medical and/or vision services, or as the Responsible Party for minor Patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities, and agree to these terms.


Close

Notice of Dr. Michael Brodsky & Associates, Inc. Policies Relating to Patient Privacy

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THIS NOTICE IS EFFECTIVE 11/10/2011 UNTIL FURTHER NOTICE.

Right to Notice

As a patient, you have the right to adequate notice of the uses and disclosures of your protected health information. Under the Health Insurance Portability and Accessibility Act (HIPAA), Dr.Michael Brodsky & Associates can use your protected health information for treatment, payment and health care operations.

a)Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment or expected to provide treatment to you.
b)Payment: We may use and disclose your health information to obtain payment for services we provide you.
c)Health Care Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competency or qualifications of healthcare professionals, evaluation of provider performance, conduction of training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization

Most uses and disclosures that do not fall under treatment, payment or healthcare operations will require your written authorization. Upon signing, you may revoke your authorization (in writing) through our practice at any time.

Emergency Situations

In the event of your incapacity or an emergency situation, we will disclose health information to a family member, or another person responsible for your care, using our professional judgment. We will only disclose health information that is directly relevant to the person's involvement in your healthcare.

Required by Law

We may use your health information when we are required to do so by law.

Abuse or Neglect

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your or other people's health or safety.

National Security

We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information to authorized federal officials required for lawful intelligence, counterintelligence and other national security activities. We may disclose health information of inmates to the appropriate authorities under certain circumstances.

Appointment Reminders

We may use or disclose your health information to provide you with appointment reminders via phone, e- mail or letter.

Accompanying Individuals

If you bring along another person or persons to your exam or office visit and allow them to accompany you in the exam room during your time with the doctor or other office personnel, it will be assumed that you are giving your permission to freely discuss your health information in front of this person or persons as it pertains to that day's visit.
We will not intentionally discuss your protected health information in front of other patients in the office and will be sensitive to these issues. However, if the discussion of glasses or contact orders, your billing, instructions pertaining to treatment or other issues occurs in the more public areas of the office, and you at any time feel uncomfortable with your level of privacy, please feel free to let us know and we will move the conversation elsewhere.

How Our Office May Contact You

Our office may contact you from time to time concerning your care. We may contact you by mail, phone, or email. We may contact you regarding your next appointment, to inform you that your order is ready, to pay an outstanding balance, or to market services in our office. As part of our recall program, LensCrafters will receive your name, address, telephone number, email address and next appointment date(s) and time(s) for the purpose of providing LensCrafters coupons and service and product Information either from this office or directly from LensCrafters; And to compare mailing lists with LensCrafters to help avoid duplicate mailings. This information may be re-disclosed and no longer protected by federal privacy regulations. This authorization is voluntary and you may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment, receive payment, or eligibility for benefits. LensCrafters/Dr Michael Brodsky & Associates. will not receive compensation for the use/disclosure of this information. You may inspect or copy the information used or disclosed. You may revoke this authorization at any time by notifying LensCrafters/Dr Michael Brodsky & Associates. in writing, except to the extent that action has been taken in reliance on this authorization; or if this authorization is obtained as a condition for obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy. This authorization expires four years from the date of my signature.

Your Rights as a Patient

  • You have the right to restrict the disclosure of your protected health information (in writing). The request for restriction may be denied if the information is required for treatment, payment or healthcare operations.
  • You have the right to receive confidential communications regarding your protected health information.
  • You have the right to inspect and copy your protected health information.
  • You have the right to amend your protected health information.
  • You have the right to receive an account of disclosures of your protected health information.
  • You have the right to a paper copy of this notice of privacy practices.

Legal Requirements

Dr. Michael Brodsky & Associates, Inc. is required by law to maintain the privacy of your protected health information. We are required to abide by terms of this notice as it is currently stated, and reserve the right to change this notice. The policies in any new notice will not be in effect until they are posted to this site, or are available within our office.

Complaints

If you have complaints regarding the way your protected health information was handled, you may submit a complaint in writing to our office. You will not be retaliated against in any manner for a complaint.

Contact Information

For further information about Dr. Michael Brodsky & Associates' privacy policies, please contact our HIPAA complaint officer, Michael Brodsky, at the following address or phone number.

Dr. Brodsky & Associates, Inc.
265 Lehigh Valley Mall, Whitehall, 18052, PA, Phone: (610) 266-6666

Close

Existing Patients

If you have moved or any of your patient information has changed please contact our office.
We will generate a pass code allowing you to verify and update your patient information.


Close