PATIENT DEMOGRAPHICS CHILDREN AND YOUTH

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Antony Moody
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1 UPDATES PATIENT DEMOGRAPHICS CHILDREN AND YOUTH Date: Child s Name: Male Female Parent or Guardian Name: Child s DOB: Child s Social Security Number: Address: Street Apt. # City State Zip Home Phone: Emergency Contact: Cell Phone: Phone Number: Person Responsible for Bills: Address: Street Apt. # City State Zip Phone: Social Security Number: Relationship: Date of Birth: PLEASE PROVIDE INSURANCE CARDS FOR COPIES Primary: Secondary: ID #: ID #: Group #: Group #: Subscriber: Subscriber: Relationship: Relationship: REFERRING DOCTOR Name: Address: Phone: Fax: PRIMARY PHYSICIAN Name: Address: Phone: Fax: Pharmacy: Pharmacy Address: Pharmacy Phone Number: DOC 110v p. 1

2 PEDIATRIC EYE CENTER PATIENT HISTORY RECORD Child s Name: Date Technician Obtained: Technician: Date of Birth: Allergies/Intolerances: NKDA PCN Sulfa Iodine (lobster/shrimp) Referring Doctor: Eye Doctor: Where do you buy your child s glasses? Primary Doctor: Endocrine: Please answer the following questions about your child s medical status and history: 1. Has your child ever been treated for any medical conditions (e.g. diabetes, high blood pressure, ADD/ADHD)? YES NO, if YES, please explain: 2. Does your child have Diabetes? YES NO, Complications: 3. Has your child ever had any serious infections? Tuberculosis: YES NO, Hepatitis: YES NO, HIV: YES NO, Syphilis: YES NO, Herpes: YES NO Other: 4. Has your child ever been hospitalized? YES NO, if YES please provide date and reason: 5. Were there any complications with pregnancy or delivery? YES NO, if YES please provide detail: 6. Was your child born premature? YES NO 7. Does your child take any eye medications? YES NO if YES, please list: 8. Does your child take any medications? YES NO, please list below: MEDICATIONS: DOC 111 v p. 1

3 PEDIATRIC EYE CENTER PATIENT HISTORY RECORD Child s Name: Date Technician Obtained: Technician: Date of Birth: 8. Has your child ever had any surgeries? YES: NO:, please list below: SURGERIES: Review of Symptoms Does your child currently have any of the following problems: Chronic fever, unexpected weight loss/gain, fatigue Yes No If yes, please explain Ear/nose/throat problems (e.g. hearing, loss, sinus problems, sore throat) Heart Problems (e.g. chest pain, irregular heartbeat, heart attack) Respiratory Problems (e.g. shortness of breath, wheezing, coughing) Gastrointestinal problems (e.g. heartburn, abdominal pain, diarrhea) Urinary problems (e.g. pain or discomfort, blood in urine) Skin problems (e.g. rashes, excessive dryness) Musculoskeletal problems (e.g. muscle aches, joint pain, swollen joints) Neurologic problems (e.g. numbness, weakness, headaches, paralysis,) Psychiatric problems (e.g. depression, anxiety) Family and Social History Do any medical or eye diseases run in your family (e.g. diabetes, high blood pressure, cancer, glaucoma, macular degeneration)? YES NO, if YES, please explain: Is your child in school? YES NO, if YES, what grade: Who does your child live with at home? DOC 111 v p. 2

4 InsuranceAuthorizations Medicare IfyouhavesomeformofMedicare,weneedyoursignatureonthefollowingstatement sothatwemaysubmityourchargetoyourinsurancecompany. IrequestthatpaymentofauthorizedMedicare/Medigapbenefitsbemadetomeoronmy behalftomooreeyecare,p.c.foranyservicesfurnishedtomebythatsupplier.i authorizeanyholderofmedicalinformationaboutmetoreleasetothehealthcare FinancingAdministrationanditsagentsanyinformationneededtodeterminethese benefitsforrelatedservices. MedicareBeneficiarySignature: Date: CommercialInsurance Ifyouhaveacommercialinsurance,weneedyoursignatureonthefollowingstatement sothatwemaysubmityourchargetoyourinsurancecompany. Iauthorizeanyholderofmedicalinformationaboutmetoreleasethisinformationtomy insurancecompany,itsintermediatesorcarriers,tomyattorney,ortoanotherphysician s office. Iherebyauthorizedirectpaymentofmedicaland/orsurgicalbenefits;toincludemajor medicalbenefitstowhichiamentitled,privateinsurance,andotherhealthplans,to MooreEyeCare.Iunderstandthat,astheseserviceswereperformedforme,Iam financiallyresponsibleforallcharges,whetherornotpaidbyinsurance. Patient ssignature: ResponsibleParty ssignature: Date: DOC103v120315p.1

5 PatientFinancialResponsibilityDisclosureStatement YoursignaturebelowformsabindingagreementbetweenMooreEyeInstitute(MEI theproviderofmedicalservices)andthepatientwhoisreceivingmedicalservicesor theresponsiblepartyforminorpatients(thosepatientsunder18yearsold). ResponsiblePartyistheindividualwhoisfinanciallyresponsibleforpaymentofmedical bills.allchargesforservicesrenderedaredueandpayableatthetimeofservice. MEDICALINSURANCE:Wehavecontractswithmanyinsurancecompanies,andwewill billthemasaservicetoyou.astheresponsibleparty,youareresponsibleifyour insurancecompanydeclinestopayforanyreason. ThepersonsigningonbehalfofthePatientastheResponsiblePartymust: InformMEIofthecurrentaddressandphonenumberforthepatientandthe responsibleparty. Presentallcurrentinsurancecardspriortoeachofficevisit. ProvideavalidreferralfromyourPrimaryCareDoctorpriortoeachofficevisit, shouldyourinsurancerequireit Verifyateachvisitthattheinsuranceandpatientdemographicinformationiscorrect Payanyrequiredcopayatthetimeofthevisit. Payanyadditionalamountowingwithin30daysofreceivingastatementfromour office.(whenmeireceivesanexplanationofbenefits(eob)fromyourinsurance company;anyamountsthatyouneedtopaywillbebilledtoyou). ReturnedCheckPolicy:Ifapaymentismadeonanaccountbycheck,andthecheckis returnedasnonsufficientfunds(nsf),accountclosed(ac),orrefertomaker(rtm), thepatientorthepatient sresponsiblepartywillberesponsiblefortheoriginalcheck amountinadditiontoa$25.00servicecharge.oncenoticeisreceivedofthereturned check,meiwillsendoutalettertonotifytheresponsiblepartyofthereturnedcheck.if aresponseisnotmadewithin30daysfromtheletterdatebythepatientorthe ResponsibleParty,theaccountmaybeturnedovertoourcollectionagencyanda collectionfeewillbeaddedtotheoutstandingbalance inadditiontothe$25.00check ServiceCharge. DOC102v082416p.1

6 NonPaymentonAccount:Shouldcollectionproceedingsorotherlegalactionbecome necessarytocollectanoverdueaccount,thepatientorthepatient sresponsibleparty, understandsthatmeihastherighttodisclosetoanoutsidecollectionagencyall relevantpersonalandaccountinformationnecessarytocollectpaymentforservices rendered.thepatient,orthepatient sresponsibleparty,understandsthattheyare responsibleforallcostsofcollectionincluding,butnotlimitedto;allcourtcosts, Attorneyfees,andacollectionfeewillbeaddedtotheoutstandingbalance. Bysigningbelow,youagreetoacceptfullfinancialresponsibilityasapatientwhois receivingmedicalservicesorastheresponsiblepartyforminorpatients.yoursignature verifiesthatyouhavereadtheabovedisclosurestatement,understandyour responsibilities,andagreetotheseterms. PatientName) Date (PleasePrint) PatientSignature Patient sguarantorname Date (PleasePrint) PatientsGuarantorSignature DOC102v082416p.2

7 Consent for Dilating Eye Drops and Pressure Measurements Dilating eye drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a better view of the inside of your eye. Dilating drops frequently blur vision for a length of time, which varies from person to person, and may make bright lights bothersome. It is not possible for your ophthalmologist to predict how much your vision will be affected. Because driving may be difficult immediately after an examination, you should not drive yourself. I hereby release the practice from any liability. In the course of examining you or taking your eye pressure on an occasion a scratch can occur in the eye. Please call us immediately after your visit if you have pain, since this can lead to corneal ulcer and possible loss of vision. This occurs very rarely. I hereby agree to allow the staff of Moore Eye Care to take my eye pressure and release the practice from any liability. Print Patient Name: Date of Birth: Patient Signature: Date: Print Name of Witness: Signature of Witness: DOC 104v p. 1

8 IauthorizeMooreEyeInstitutetodisclosemyprotectedhealthinformationto: Name: Address: City: State: Zip: Theprotectedhealthinformationtobeusedordisclosedisasfollows:(Pleaseselectallthatapplyor recordotherinformationinthespaceprovided.) Entiremedicalrecord Medicationlist Laboratoryresultsfrom to. (Date)(Date) Xrayorotherimagingfrom to. (Date)(Date) Officenotesfrom to. (Date)(Date) Otherinformation(pleasedescribe): Thisinformationisbeingused/disclosedforthefollowingpurpose: Atmyrequest IunderstandthatIhavetherighttorevokethisauthorization,inwriting,atanytimebygivingnoticeof myrevocationtotheprivacyoffice,excepttotheextentthatactionhasbeentakeninrelianceonthis authorization.unlessotherwiserevoked,thisauthorizationwillexpireon (insertdateoreventontheline). Iunderstandthatinformationdisclosedasaresultofthisauthorizationmaybesubjecttodisclosureby therecipientandmaynolongerbeprotectedbyfederalorstatelaw.thecoveredentitymaynot conditiontreatment,payment,enrollmentoreligibilityforbenefitsonwhetherisignthisauthorization except(1)ifmytreatmentisrelatedtoresearch,or(2)ifhealthcareservicesareprovidedtomesolely forthepurposeofcreatingprotectedhealthinformationfordisclosuretoathirdparty. PrintNameofPatient: DateofBirth: Patient/RepresentativeSignature: Date: PrintNameofPersonalRepresentative: DOC105v120315p.1

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13 ACKNOWLEDGEMENTOFRECEIPT OFNOTICEOFPRIVACYPRACTICE IhavereceivedapapercopyofMooreEyeInstitute snoticeofprivacypractices. Name: Signature: Date: DOC107v120315p.1

Social Security Number: Date of Birth: May we contact you at work? Yes No PLEASE PROVIDE INSURANCE CARDS FOR COPIES

Social Security Number: Date of Birth: May we contact you at work? Yes No PLEASE PROVIDE INSURANCE CARDS FOR COPIES UPDATES PATIENT DEMOGRAPHICS Date: Single Married Widowed Divorced Name: Male Female Address: Street Apt. # City State Zip Email Address: Social Security Number: Phone: Home: Cell: Occupation: Emergency