New Patient History Forms "*" indicates required fields FINANCIAL AND OFFICE POLICIES ASSIGNMENT OF BENEFITSPlease read and sign in the space providedDate* MM slash DD slash YYYY Print Patient name* First Last DOB* Month Day Year I have requested and consent to treatment from Advanced Eye Group, LLCWe require you to bring your INSURANCE card and ID to every office visit. It is your responsibility to keep us informed of any changes to your address, phone, or insurance information.PATIENTS WITH INSURANCE: If you do not inform us you have a vision/medical insurance plan(s), we will assume there is none.Your insurance policy is a contract between you and your insurance company. The ultimate responsibility for all charges regardless of what your insurance does/does not pay is yours including but not limited to deductible, coinsurance or copay.We do not guarantee the accuracy of benefit information received by the insurance companiesThis office, with NO EXCEPTIONS will not back date, post authorize, or refund fees after services are rendered due to lack of notification of vision/medical benefitsit's your responsibility to obtain any insurance referrals (if required) from your primary care Doctor. If a referral has not been obtained PRIOR to your visit, your appointment will be rescheduled (or you may pay out of pocket fees). You may file my own claim if you discover you have vision or medical benefits after services/products are renderedMINOR/DEPENDENT CHILDREN: An adult guardian must be present to sign any legal documents/forms, and be able to make decisions on the child's behalfIn cases of separation or divorce, that person must be prepared to supply the SUBSCRIBER name, DOB, social security number (or last 4#), address, and phone. If we do not have this information, the visit will be out of pocketPATIENTS WITHOUT INSURANCE: Identification must be presented each visit. Payment is due at the time services are rendered.AUTHORIZATION TO RELEASE INFORMATION: I authorize the release of any medical information to my insurance carrier and/or a licensed physician or health-care provider concerning my illness and treatment. I also request payment of my insurance benefits to Advanced Eye Group, LLC. APPROVED HIPAA CONTACTS:(Except your Doctors) With whom may we release information to? (If the end date is left blank, the duration is indefinite unless revoked in writing) Name First Last Relationship Billing/Account information Medical information Name First Last Relationship Billing/Account information Medical information HIPAA ACKNOWLEDGEMENT: I have been presented the Notice of Privacy Policy of Advanced Eye Group, LLC and have been offered a copy of such policy to keep for my records. I want a copy of the written policy and have received such. I decline a copy of the written policy Signature of patient/guardian*Representative name (if other than patient PRINT First Last PROFESSIONAL SERVICES AND FEESREFRACTION: Vision test: Part of a Routine exam to determine your prescription for the best possible vision.NOT covered by most medical insurances $37 fee is collected at time of service and is in addition to any copay As part of the Comprehensive eve exam, it is recommended ALL PATIENTS have the internal health of the eye thoroughly evaluated every year. This is best done by Dilation/OptomapDILATION: Eye drops to enlarge the pupils to examine the retina/back of the eye.IS COVERED by medical insurancesWill have blurred vision and light sensitivity for 4-6 hours. OPTOMAP DIGITAL IMAGING: A high resolution image of the retina/macula. It becomes a permanent part of your medical record for comparison for changes over time.NO BLURRINESS OR LIGHT SENSITIVITYNOT covered by any insurance$37 fee in addition to any copay and refraction feesDilation may still be required in some instancesCONTACT LENSES: Are medical devices worn on the eyes.Federal regulations require an evaluation and prescription ANNUALLY to avoid infection/injury and to assure the pest fit and vision. Federal regulations stipulate a contact lens prescription is valid for 1 year. Evaluation fee is separate from copayirefraction fees and is collected at the time of service. EVAL: $35 (same brand/type of lens} REFIT: $59-399 (new brand/type of lens)NEW FIT $159-$199 Initial fitting and training. Trial lenses and follow ups includedContact lens supply is NOT included I understand the above policies/fees and take full responsibility for any activities I may perform after dilation. Please check all that apply OPTOMAP digital imaging (337 fee) ORO DILATION {no additional fee) REFRACTION ($37 fee if not covered by insurance) CONTACT LENS evaluation/fitting ($35-$199 fee) Patient name (print)* First Last Date* MM slash DD slash YYYY Signature of patient/guardian*Representative name (if other than patient PRINT) First Last Patient RegistrationName* First Last Select one: Dr Mr Mrs Ms Miss Jr Sri I II III Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home Phone*Work PhoneCell PhoneSelect one of the following that applies to the patient: I am employed Full time Part time Self employed Homemaker Retired Currently unemployed Employer: Occupation: Date Of Birth* MM slash DD slash YYYY Sex M F Social Security numberSelect one I am: Married Single Widowed Domestic Partner If student, select one: Fulltime Parttime Medical Doctor: MD Phone #:Email Your email is only used for our office's professional purposes and will never be shared with any outside persons or sources. For New Patients: Whom may we thank for referring you Spouse or Parent InformationName First Last DOB MM slash DD slash YYYY Relationship to patient: Employer: Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work PhoneOCULAR HISTORYDo you wear glasses? Yes No How old is your present pair of lenses Do you wear contact lenses? Yes No What type? Rigid Soft Toric Multifocal Monovsion Do you wear them ? Full Time Part Time How frequently do you replace them? Have you had refractive surgery? Yes No Date MM slash DD slash YYYY Type Are you currently experiencing any of the following problems with your eyes? Check the box if “Yes" Blurred Vision Flashes / Floaters in Vision Excess Tearing / Watering Loss of Vision Halos / Glare / Light Sensitivity Eye Pain or Soreness Loss of Side Vision Dryness Distorted Vision Sandy or Gritty Feeling Mucous Discharge Double Vision Burning Inflammation of the Eyelid Tired Eyes Itching Styes or Chalazion Redness Have you been diagnosed with any of the following ocular problems? Check the box if “Yes" Cataracts Lazy Eye / Amblyopia Dry Eye Eye Injury Macular Degeneration Other Glaucoma Retinal Detachment / Disease MEDICAL HISTORYList any medications you are currently taking (include oral contraceptives, aspirin, over the counter medications)Are you allergic to any medications? Yes No Which ones? Are you pregnant and / or nursing? Yes No FAMILY HISTORY (parents, grandparents, siblings, children; living or deceased) for the following conditionsGlaucoma Yes No Cancer Yes No Relation to you Relation to you Macular Degeneration Yes No Heart disease Yes No Relation to you Relation to you Retinal Detachment Yes No High blood pressure Yes No Relation to you Relation to you Blindness Yes No Kidney disease Yes No Relation to you Relation to you Auto-immune diseases Yes No Relation to you
