Dear Patient, Thank you for choosing Georgia Eye Associates. We strive to provide you with state-of-the-art eye care in comfortable surroundings.
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- Sylvia Blankenship
- 8 years ago
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1 Donald E. Poland, M.D. Kris F. Gillian, M.D. Dickie McMullan, M.D. Frank L. Winski, O.D. Brian A. Kahn, O.D. Brigette Rabitsch, O.D. Dear Patient, Thank you for choosing Georgia Eye Associates. We strive to provide you with state-of-the-art eye care in comfortable surroundings. Attached are maps and directions to our three offices. Please note the location of your appointment and follow the corresponding directions. If you need further assistance, do not hesitate to give us a call. Please complete the enclosed forms and bring them with you when you come in for your appointment. Your medical history is very important to us. A complete eye exam includes dilation. Dilation involves widening the pupils using eye drops. The effects can last up to several hours. It may cause light sensitivity and blurred near vision, but most people have no trouble driving after the exam. If you are concerned about driving after dilation, please bring someone to drive you. If you wear contacts, please call our office to inquire about our contact lens policies and prices. We cannot release contact lens prescriptions to new patients until we have fit your eyes. If you must change or cancel you appointment, please try and give at least 24 hours notice. Your consideration is greatly appreciated. Melanie Peeler, O.D. Sincerely, Donald E. Poland, M.D. Kris F. Gillian, M.D. Dickie McMullan, M.D. Frank L. Winski, O.D. Brian A. Kahn, O.D. Brigette Rabitsch, O.D. Melanie Peeler, O.D. Lawrenceville 771 Old Norcross Road Suite 150 Lawrenceville, GA Fax: Atlanta (Buckhead) 3120 Maple Drive Atlanta, GA Fax: Tucker 2368 Main Street Suite 2 Tucker, GA Fax:
2 Lawrenceville Office 771 Old Norcross Rd., Terrace Park Medical Building Suite 150, Lawrenceville, GA Phone: Fax: From the North (Buford, Braselton): Take I 85 South to Exit 111 (Suwanee). Turn left onto GA-317/Lawrenceville Suwanee Rd and go east. Travel six miles to the Old Norcross Rd. intersection. Georgia Eye Associates is on the left at the intersection (blue building). From the South (Downtown, Midtown, Buckhead): Take I 85 North to Route 316. Travel approximately three miles and exit route 120/Duluth Highway. Turn left onto 120/Duluth Highway. Travel 0.5 miles to Lawrenceville Suwanee Rd. Turn left onto Lawrenceville Suwanee Rd. Travel one mile. Georgia Eye Associates is on the left at the Old Norcross Rd. intersection (blue building). From the East: Take 316 westbound and exit 120 East (Duluth Highway). Turn right at 120/Duluth Highway. Travel 0.5 miles to Lawrenceville Suwanee Rd. Turn left onto Lawrenceville Suwanee Rd. Travel one mile. Georgia Eye Associates is on the left at Old Norcross Rd. intersection (blue building). Atlanta (Buckhead) Office 3120 Maple Dr., Atlanta, GA Phone: Fax: From the North (Gainesville, Lawrenceville, Duluth): Take I 85 South to exit 88 Cheshire Bridge/Lenox Rd/GA-400. Turn right onto Lenox Rd and drive about 2.5 miles. Turn left onto Peachtree Rd., NE Crossover Piedmont Rd. Take a left onto Maple Dr. Georgia Eye Associates is on the right. From the South (Airport,Downtown, Midtown): Take I 85 North and merge onto GA-13 N via Exit 86. Take the GA-237 N/Piedmont Rd. ramp. Turn right onto Piedmont Rd. NE/GA-237. Turn left onto East Paces Ferry Road NE. Turn right onto Maple Dr. Georgia Eye Associates is on the left. Tucker Office 2368 Main St., Suite 2, Tucker, GA Phone: Fax: From the North (Gainesville, Lawrenceville, Duluth): Take I 85 South to Exit 96 (Pleasantdale Rd). Turn left. Continue along Pleasantdale Rd. It will turn into Chamblee Tucker Rd. Turn left onto LaVista Rd. (Tucker High School will be on the left.) At the first traffic light, turn right onto Main St. Georgia Eye Associates is the 5th building on the right. From the South (Airport, Downtown, Midtown): Take I 85 North to I 285 East to Exit 37 Turn left onto LaVista Rd. Travel about 2 miles. Turn right onto Main St. (Tucker High School will be on the left) Georgia Eye Associates is the 5th building on the right.
3 NEW PATIENT HISTORY RECORD Name: Date: PAST EYE HISTORY (List any previously diagnosed eye illness or operation) CURRENT EYE MEDICATIONS (List all eye drops or ointments) PAST MEDICAL HISTORY YES NO YES NO TUBERCULOSIS HIGH BLOOD PRESSURE CANCER KIDNEY DISEASE DIABETES THYROID DISEASE BLOOD DISORDERS LUNG DISEASE HEART DISEASE NEUROLOGIC DISORDERS OTHER (DESCRIBE) MAJOR SURGERIES (DESCRIBE) MEDICATIONS (List all oral medications which you take on a regular basis) ALLERGIES (List all drugs or substances to which you are allergic) FAMILY HISTORY DO ANY MAJOR ILLNESSES OR EYE DISEASES RUN IN YOUR FAMILY? ( ) YES ( ) NO IF YES, EXPLAIN: SOCIAL HISTORY DO YOU SMOKE? ( ) YES ( ) NO IF YES, HOW MUCH? DO YOU DRINK ALCOHOL? ( ) YES ( ) NO IF YES, HOW MUCH? HAVE YOU EVER USED DRUGS? ( ) YES ( ) NO IF YES, EXPLAIN: HAVE YOU EVER HAD A BLOOD TRANSFUSION? ( ) YES ( ) NO REVIEW OF SYSTEMS DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING PROBLEMS: IF YES, please explain: CHRONIC FEVER, UNEXPECTED WEIGHT LOSS/GAIN, FATIGUE ( ) YES ( ) NO EAR/NOSE/THROAT PROBLEMS (e.g., hearing loss sinus problems, sore throat) HEART PROBLEMS (e.g., chest pain, irregular heart beat) RESPIRATORY PROBLEMS (e.g., shortness of breath, wheezing, coughing) GASTROINTESTINAL PROBLEMS (e.g., heartburn, abdominal pain, diarrhea, vomiting) 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) ALLERGIC PROBLEMS (e.g., hay-fever, sinus problems, runny nose) ARE YOU INTERESTED IN LEARNING MORE ABOUT LASIK LASER VISION CORRECTION? ( ) YES ( ) NO History Reviewed. ( ) No changes ( ) Changes as noted Physician: Date: History Reviewed. ( ) No changes ( ) Changes as noted Physician: Date: History Reviewed. ( ) No changes ( ) Changes as noted Physician: Date:
4 PATIENT INFORMATION Date: PATIENT NAME: (LAST) (FIRST) (MI) ADDRESS: (STREET (P.O. BOX) (APT #) (CITY) (STATE) (ZIP CODE) HOME PHONE: SOCIAL SECURITY NO: PATIENT EMPLOYED BY: OCCUPATION: BUSINESS PHONE: PATIENT SEX: ( ) MALE ( ) FEMALE AGE: DATE OF BIRTH: CELL PHONE: MARITAL STATUS: ADDRESS: PERSON TO NOTIFY IN AN EMERGENCY: PHONE: INSURANCE POLICY HOLDER S INFORMATION (Complete only if someone other than the patient is insurance policy holder) NAME: RELATION TO PATIENT: ADDRESS: CITY, STATE, ZIP: HOME PHONE: SOCIAL SECURITY NO: DATE OF BIRTH: SEX: ( ) MALE ( ) FEMALE EMPLOYER ADDRESS: BUSINESS PHONE: INSURANCE INFORMATION (Complete only if you have made prior arrangements with receptionist to file insurance) NAME OF PRIMARY INSURANCE COMPANY: NAME OF SECONDARY INSURANCE COMPANY: PLEASE NOTE: WE FILE INSURANCE AS A COURTESY FOR OUR PATIENTS. WE DEAL WITH OVER 700 INSURANCE CARRIERS AND IT IS IMPOSSIBLE FOR US TO KNOW THE SPECIFIC DETAILS ON HOW EACH INSURANCE WORKS. IT IS YOUR RESPONSIBILITY TO KNOW THE SPECIFICS OF YOUR PLAN. WE SUGGEST YOU CALL YOUR INSURANCE CARRIER BEFORE YOUR VISIT TO SEE IF: 1) THE PROVIDER YOU ARE SEEING IS A COVERED PROVIDER; 2) YOU HAVE A DEDUCTIBLE TO MEET BEFORE YOUR INSURANCE PAYS; AND, 3) YOUR INSURANCE COMPANY REQUIRES A REFERRAL FROM YOUR PRIMARY CARE PHYSCIAN BEFORE BEING SEEN. IF THE PURPOSE OF YOUR VISIT IS A ROUTINE EYE EXAM THEN MAKE SURE YOU HAVE ROUTINE VISION COVERAGE. ASSIGNMENT AND RELEASE: I HEREBY AUTHORIZE MY INSURANCE BENEFITS BE PAID DIRECTLY TO THE PHYSCIAN AND ACKNOWLEDGE THAT I AM FINANCIALLY RESPONSIBLE FOR ANY NON-COVERED SERVICES OR UNPAID BALANCE, AND ANY LEGAL FEES NECESSARY TO COLLECT THE UNPAID BALANCE. I ALSO AUTHORIZE MY PHYSCIAN TO RELEASE ANY INFORMATION REQUIRED IN PROCESSING OF THESE BENEFITS. PATIENT S SIGNATURE: DATE (rev 9-14) METHOD OF PAYMENT: ( ) CASH ( ) CHECK ( ) CREDIT CARD ( ) OTHER
5 PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I hereby give my consent for Georgia Eye Associates to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). (Georgia Eye Associate's Notice of Privacy Practices provides a more complete description of such uses and disclosures.) I have the right to review the Notice of Privacy Practices prior to signing this consent. Georgia Eye Associates reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Georgia Eye Associates Privacy Officer at 771 Old Norcross Road, Suite 150, Lawrenceville, GA With this consent, Georgia Eye Associates may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others. With this consent Georgia Eye Associates may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked Personal and Confidential. With this consent, Georgia Eye Associates may to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Georgia Eye Associates restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By signing this form, I am consenting to Georgia Eye Associate's use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent that practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Georgia Eye Associates may decline to provide treatment to me. Signature of Patient or Legal Guardian Patient's Name Date Print Name of Patient or Legal Guardian
6 Donald E. Poland, M.D. Kris F. Gillian, M.D. Dickie McMullan, M.D. Frank L. Winski, O.D. Brian A. Kahn, O.D. Brigette Rabitsch, O.D. Melanie Peeler, O.D. OFFICE POLICY ON MANAGED CARE INSURERS In order to accommodate the needs and requests of our patients, we have enrolled in numerous managed care insurance programs. While we are pleased to be able to provide this service to you, it is extremely difficult for us to keep track of all the individual requirements of the plans. Each one has different stipulations regarding how often services may be rendered and, even more importantly, where those services may be performed. Even within the same insurance company, the plans differ depending upon what type of contract your employer has negotiated. Providing quality eye care for our patients is our primary concern. We are more than willing to provide that care within your insurance contracts guidelines if you let us know at the time of each service what those guidelines are. Unfortunately, if you do not inform us of any special requirements in your contract and we subsequently perform services such as photos, visual field or procedures that are not covered, we will have no choice but to bill you directly for those charges. Payment for those charges is then your responsibility. In event that services are provided and your coverage is not in effect on that day then fees submitted and denied by your carrier will become your responsibility. With your cooperation and help, you should be able to receive all the benefits offered to you, and we will be able to concentrate on caring for your eye needs. Lawrenceville 771 Old Norcross Road Suite 150 Lawrenceville, GA Fax: Atlanta (Buckhead) 3120 Maple Drive Atlanta, GA Fax: Tucker 2368 Main Street Suite 2 Tucker, GA Fax:
7 Whom May We Thank for Referring You? Please Circle Office Location: Lawrenceville Buckhead Tucker Referral Information: Please check all that apply Family/Friend Name: Referring Doctor s Name: Referring Optometrist s Name: Insurance Referral: Georgia Eye Associates Website Internet Referral: Google Yahoo Bing Other Drove by/walked by Yellow Pages Yellow Pages.COM (online) Christ the King Ad Mercer University Health Fair Tucker Day ZocDoc Other (Please explain): Your Name Date
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PATIENT INFORMATION FORM. Name: Address: City: State: Zip: Social Security Number: Telephone Numbers Home: Age: Sex: M / F Work: Email: Cell:
PATIENT INFORMATION FORM Name: Address: City: State: Zip: Social Security Number: Telephone Numbers DOB: Home: Age: Sex: M / F Work: Email: Cell: Marital Status: Single Married Spouse s Name: Widowed Divorced
IMS Allergy & Immunology New Patient Registration Sheet. Personal Information
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WELCOME TO OUR OFFICE
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Patient Demographics Sheet
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North Country Holistic Care Center PATIENT REGISTRATION FORM. Patient Information. Name: Address: City: State: Zip: Email
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POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
Emory Eye Center New Patient Questionnaire
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Cutting Edge Eye Care
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ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION
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INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION
PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan
Patient Checklist. Expect to pay your co-pays and non-covered services on the day of service.
Welcome to Cedar Run Eye Center. We look forward to your visit with us! Enclosed you will find: Registration Form History Form Patient check list with a map on the back side Patient Name: Date of Appointment:
PATIENT/PARENT/GUARDIAN SIGNATURE
PATIENT REGISTRATION PATIENT S NAME: SEX MALE FEMALE DOB: SOCIAL SECURITY #: CITY/STATE/ZIP: PHONE # GUARANTOR INFORMATION (if responsible party is not the patient) MOTHER S NAME: DOB: SS#: CITY/STATE/ZIP:
REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)
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THINK PHYSICAL THERAPY PATIENT INFORMATION Please present your insurance card(s) for copying. Patient Name: Sex: Date of Birth: Age:
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St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
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Medical History Questionnaire
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PATIENT INFORMATION PATIENT ETHNICITY / RACE SPOUSE INFORMATION EMERGENCY CONTACT
Conway Orthopaedic & Sports Medicine Clinic, PA 550 Club Lane Conway AR, 72034 501.329.1510 Account #: : Patient's Name: Patient's Street Address: Apt #: of Birth: Patient's Mailing Address/PO Box: Sex:
Dallas Neurosurgical and Spine Associates, P.A Patient Health History
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PATIENT REGISTRATION
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Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598
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Name Today's Date Sex. Street Address City State Zip Code. Home # Work # Cell # Would you like to receive text confirmations:
Patient Information 219 Old Hook Road Westwood, NJ 07675 Office: (201) 664-0847 Fax: (201) 664 8890 E-Mail: Mail@2020nj.com Thank you for choosing Valley Eye Associates for you eyecare needs. Please complete
Patient Demographic Sheet
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PATIENT REGISTRATION FORM
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PENNSYLVANIA PLASTIC SURGERY ASSOCIATES, P.C. Howard S. Caplan, M.D. Francine A. Cedrone, M.D. Account #
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19235 N Cave Creek Rd #104 Phoenix, AZ 85024 Phone: (602) 485-3414 Fax: (602) 788-0405
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The Dermatology & Laser Group of Irvine, A.M.C. 16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115
16300 Sand Canyon Avenue, Suite 612 Irvine, CA 92618-3706 Phone# 949-753-1001 Fax# 949-753-1115 (Please Print) Today s Date / / PATIENT INFORMATION Name Last First M.I. Maiden Name: SS# Email: Mr. Ms.
LOUISIANA PHYSICAL THERAPY CENTERS OF PINEVILLE, LLC 1135 EXPRESSWAY DRIVE, SUITE 100B PINEVILLE, LA 71360 (318) 487-6525 FAX: (318) 487-6527
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PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)
REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER:
How To Get A Medical Checkup
NAFISA TEJPAR, M.D., F.A.C.S. 2501 N. Orange Ave, Ste 513 Orlando, FL 32804 (407) 894-1280 APPOINTMENT TIME: (Please be at the office 30 minutes before) Welcome to NAFISA TEJPAR, M.D. PA. We appreciate
Hello, Please note: The following information will be needed at your appointment:
Hello, You are receiving this mailing because you or a family member have an upcoming appointment at the Albany Medical Center s Neurology Group as noted above. Our goal is to provide you with the best
Referrals It is your responsibility to bring your referral if required. Failure to do so may result in cancellation of your appointment.
Welcome to Capital Endocrinology! We are happy to have you as a patient in our practice. Please take note of the following policies. Following these policies will help in making your visit as efficient
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944
4765 Carmel Mountain Rd. Ste 202, San Diego, CA 92130 Phone (848) 847-0055 Fax (858) 847-9944 Dear Patient, Your insurance may pay your total bill for services rendered by Pilates People Torrey Hills.
In order to bill your Insurance, Please fill out the following information completely. PLEASE PRINT AND BRING TO YOUR APPOINTMENT
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Dear Patient, We look forward to seeing you.
Dear Patient, Welcome to Mosier Eye Center! We appreciate your selection of our office and we look forward to serving you for all your eye care needs. This packet was created to provide you with some valuable