Online Patient Form

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Demographics


Patient Information
                       FirstLastMI
                      
Address: Apt/Suite #:
City: State: ZipCode:
Home Phone: Cell Phone:
Sex Contact Method:
Email Referred By:
Birthday Occupation
Billing Information Is The Billing Address the Same?
FirstLastMI
AddressApt/Suite #
CityStateZipCode
Home Phone:

Medical Insurance

Insurance Information
Employer that provides insurance coverage:

Medical Insurance Name:
Insurance ID:
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:
SSN:
Employer/School:

Vision Insurance

Vision Insurance Information
Insurance Name:
Insurance ID:
(VSP ID Number is the Last 4 of Primary SSN)
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:
SSN:
Employer/School:

Medical History

Medical History
Reason for Visit: Secondary Reasons:


Please check if you have these symptoms or past conditions:
Red Eyes
Watery Eyes
Burning Eyes
Dry Eyes
Itchy Eyes
Painful Eyes
Discharge/Build up in Eyes
Stye/Swollen Eyes
Feels like something in eye
Flashing Lights
Floating Spots
Suddenly Blurred Vision
Cataracts
Mascular Degen (Past or Present)
Freckle/Hole/Tear in the back of the eye


Please check if you do not take any medications.
Drug Allergies: No Known Drug Allergies

Name of Primary Care Doctor:
Office Name and City:

    You   Mom   Dad   Sibling   None
Diabetes:                        
High BP:                        
Thyroid Disease:                        
Heart Disease:                        
Cancer:                        

Eye History
Last Eye Exam: By Doctor:

    You   Mom   Dad   Sibling   None
Glaucoma:                        
Macular Degen:                        
Retinal Disease:                        
Cataracts:                        
Lazy/Crossed Eye:                        

Eye Injury/Surgery/Laser:
Other Eye History:
Interested in contacts?:

Have you worn contacts lenses in the past? What type of contacts have you worn or are currently wearing?:

Visual Tasks

Do you wear glasses?:

Type of Glasses that you have at home:

Where last glasses were bought:

Family members that wear contacts/glasses:

Acknowledge and Submit

PT ACKNOWLEDGEMENTS

1) FINANCIAL RESPONSIBILITY/Medicare ABN

I (the patient/responsible member) understand that:
Professional fees will be submitted to patient's vision and/or medical insurance. Patients will be billed for any un-met deductibles, co-insurance, etc. I authorize the payment of insurance benefits to this service provider. I agree to be financially responsible for any balance not paid by my insurance plan. I understand that professional fees are non-refundable.
  1. Routine eye exams with refractive (well) reasons for visit will be billed to patient or to patient's medical or vision insurance carrier that the doctor's office participates in.

  2. Eye exams with medical (sick) reasons for visit will be billed to patient or to patient's medical insurance carrier that the doctor's office participates in.

  3. Contact lens evaluation includes f/u contact lens evaluation for about 60 days. Any f/u past 60 days will be charged $50 and for any evaluation past 6 months will need a new evaluation.

  4. Medicare Part B ABN. Medicare does cover exams a medical evaluation of the eye at 80% coverage. Either you or your secondary insurance will be responsible for the 20% coverage or the $183 part B deductible if not met. Medicare does not cover refraction or wellness eye check.
2) HIPAA

I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I acknowledge that I have have been given the opportunity to receive a copy of the Notice of Privacy Practices and that I may contact the practice at any time to obtain a current copy of the Notice of Privacy Practices.

3) IMPORTANCE OF RETINAL EVALUATION

Your eyes are one of the few places in your body where your micro vessels can be seen non-invasively. Evaluation of the peripheral retina (micro vessels of the eye) is important and if not evaluated potentially sight threatening eye conditions such as eye diabetes, macular degeneration, retinal detachments, glaucoma, eye tumors etc. can go undetected. Therefore, all our patients are evaluated via the 2 minute Optomap retinal imaging unless a waiver is signed declining it. Wellness Optomap imaging is not a fully covered service with most insurances including Eyemed and VSP and has a $39 copay.

Optos Retinal Imaging (2 mins)
No blurry vision
No Light Sensitivity
Takes less than two minutes
Permanent digital image
Dilation Drops (25 mins)
Blurry vision 3-5 hours
Light Sensitive 4-6 hours
Adds an additional 25 mins to visit
No permanent record of retina

I release 2020 Eye Dr and the examining optometrist from any liability if my decision is not to return
or to not evaluate my peripheral retina or the retina of the person that I am the responsible adult for.

Signature: Date:

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