New Patient History Forms

FINANCIAL AND OFFICE POLICIES ASSIGNMENT OF BENEFITS

Please read and sign in the space provided

Print Patient name

First Last

DOB

Date

I have requested and consent to treatment from Advanced Eye Group, LLC

We require you to bring your INSURANCE card and ID fo every office visitIt 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 companies
This 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 benefits
it'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 rendered

MINOR/DEPENDENT CHILDREN:

An adult guardian must be present to sign any legal documentsfforms and be able to make decisions on the child's behalf
In 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 pocket

PATIENTS WITHOUT INSURANCE:

Identification must be presented each visit. Payment is due at the time services are rendered.

AUTHORIZATION TO RELEASE INFORMATION: authorize the release of any medical information to my insurance carrier or {o a licensed physician or health-care provider concerning my illness and trealment. 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: 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 FEES

REFRACTIONVision 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/Optomap

DILATION:

eye drops to enlarge the pupils to examine the retina/back of the eye.

IS COVERED by medical insurances
Will have blurred vision and light sensitivity for 4-6 hours.

OPTOMAP DIGITAL IMAGING: a high resalution image of the retina/macula. It becomes a permanent part of your medical record for comparison for changes over time.

NO BLURRINESS OR LIGHT SENSITIVITY
NOT covered by any insurance
$37 fee in addition to any copay and refraction fees
Dilation may still be required in some instances

CONTACT 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 included
Contact 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)

Decline both Optomap and dilation against Doctors recommendation.

REFRACTION ($37 fee if not covered by insurance)

CONTACT LENS evaluation/fitting ($35-$199 fee)

Patient name (print)

First Last

Date

Signature of patient/guardian

Representative name (if other than patient PRINT)

First Last

Patient Registration

Name

First Last

Select one:

Address

Street Address City State / Province / Region ZIP / Postal Code

Home Phone

Work Phone

Cell Phone

Select 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

Sex

Social Security number

Select one I am:

If student, select one:

Fulltime

Parttime

Medical Doctor:

MD Phone #:

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 Information

Name

First Last

DOB

Relationship to patient:

Employer:

Address:

Work Phone

OCULAR HISTORY

Do you wear glasses?

Yes

How old is your present pair of lenses

Do you wear contact lenses?

Yes

What type?

Do you wear them ?

Full Time

Part Time

How frequently do you replace them?

Have you had refractive surgery?

Yes

Date

Type

Are you currently experiencing any of the following problems with your eyes? Check the box if “Yes"

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 HISTORY

List any medications you are currently taking (include oral contraceptives, aspirin, over the counter medications)

Are you allergic to any medications?

Yes

Which ones?

Are you pregnant and / or nursing?

Yes

FAMILY HISTORY (parents, grandparents, siblings, children; living or deceased) for the following conditions

Glaucoma

Yes

Cancer

Yes

Relation to you

Macular Degeneration

Yes

Heart disease

Yes

Relation to you

Retinal Detachment

Yes

High blood pressure

Yes

Relation to you

Blindness

Yes

Kidney disease

Yes

Relation to you

Auto-immune diseases

Yes

Relation to you

We have moved! Our new address is 206 N. Main Road. Vineland, NJ 08360

FINANCIAL AND OFFICE POLICIES ASSIGNMENT OF BENEFITS

PATIENTS WITH INSURANCE:

MINOR/DEPENDENT CHILDREN:

PATIENTS WITHOUT INSURANCE:

PROFESSIONAL SERVICES AND FEES

DILATION:

CONTACT LENSES:

Patient Registration

Spouse or Parent Information

OCULAR HISTORY

MEDICAL HISTORY

FAMILY HISTORY (parents, grandparents, siblings, children; living or deceased) for the following conditions

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