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 Contact: Date of Birth: Work: May we contact you at work? Yes No Employer: Phone Number: Person Responsible for Bills: Address: Street Apt. # City State Zip Phone: Relationship: Spouse Dependent Other Social Security Number: Date of Birth: Primary: ID #: Group #: Subscriber: Relationship: ID #: Auto Workers Comp PLEASE PROVIDE INSURANCE CARDS FOR COPIES FOR MEDICARE MEMBERS Secondary: ID #: Group #: Subscriber: Relationship: Effective Part A: Part B: THE FOLLOWING MUST BE COMPLETED FOR AUTO ACCIDENT OR WORKERS COMPENSATION Date of Accident/Injury: Claim #: Adjuster/Contact: Adjuster/Contact Phone: Insurance: Address: REFERRING DOCTOR Name: Address: Phone: Fax: PRIMARY PHYSICIAN Name: Address: Phone: Fax: DOC 108v090116 p. 1
PATIENT HISTORY RECORD Date Technician Obtained: Technician: Name: Date of Birth: Allergies/Intolerances: NKDA PCN Sulfa Iodine (lobster/shrimp) Referring Doctor: Eye Doctor: Primary Doctor: Endocrinologist: Cardiologist: Where did you buy your glasses? Please answer the following questions about your medical status and history: 1. Have you ever been treated for any medical conditions (e.g. diabetes, high blood pressure, arthritis, lupus, sarcosis)? YES NO If YES, please explain: 2. If you have diabetes, in what year were you diagnosed? 3. If you have hypertension, in what year were you diagnosed? 4. If you have diabetes, do you have any complications? Impotence: YES NO Foot Disease: YES NO Kidney Disease: YES NO Eye Disease: YES NO 5. If you have diabetes, do you take insulin? YES NO 6. Have you ever had any of the following infections? Tuberculosis: YES NO Hepatitis: YES NO HIV: YES NO Syphilis: YES NO Herpes: YES NO 7. Have you ever been hospitalized? YES NO If YES, please provide date and reason: 8. Do you take any eye medications? YES NO If YES, please list: DOC 109v090116 p. 1
Name: Date of Birth: 9. Have you ever had any surgeries? YES NO If Yes, please list below: SURGERIES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 10. Do you take other medications? YES NO If YES, please list below: MEDICATIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 11. Have you previously had any eye problems? YES NO If YES, please list below: EYE PROBLEMS Cataract Surgery Glaucoma Retina (Surgery/Laser) Macular Degeneration Diabetic Retinopathy Amblyopia (Lazy Eye) Right Left When DOC 109v090116 p. 2
Name: Date of Birth: Review of Symptoms: Do you currently have any of the following problems? YES NO If YES, please explain Chronic fever, unexpected weight loss/gain, fatigue 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, stroke) Psychiatric problems (e.g., depression, anxiety) Family and Social History 1. Do any medical or eye diseases run in your family (e.g., diabetes, high blood pressure, cancer, glaucoma)? YES NO If YES, please explain: 2. Do you smoke? YES NO If YES, how much? 3. Do you drink alcohol? YES NO If YES, how much? 4. Do you have a history of drug abuse? YES NO When? Where? 5. If employed, how many hours per week do you work? 6. What is your occupation? DOC 109v090116 p. 3
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
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
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
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 104v120315 p. 1
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
DOC106v092313p.1
DOC106v092313p.2
DOC106v092313p.3
DOC106v092313p.4
ACKNOWLEDGEMENTOFRECEIPT OFNOTICEOFPRIVACYPRACTICE IhavereceivedapapercopyofMooreEyeInstitute snoticeofprivacypractices. Name: Signature: Date: DOC107v120315p.1