items or information listed below and bring to your first visit:

Transcription

1 ALAN L. WAGNER, M.D. F.A.C.S. DISEASES & SURGERY OF RETINA & VITREOUS MACULAR DEGENERATION DIABETIC RETINOPATHY RETINAL DETACHMENT ADULT & PEDIATRIC RETINAL SURGERY OCULAR ONCOLOGY / BRACHYTHERAPY INDOCYANINE GREEN ANGIOGRAPHY CLINICAL RESEARCH TRIALS Dear Patient, Our records indicate you have an upcoming scheduled appointment at the Wagner Macula & Retina Center with Alan L. Wagner, M.D., F.A.C.S., who specializes in diseases of the retina and vitreous. During your time with us we will work as a team to provide the best care for your eyes. To aid in your care, please complete the enclosed forms, items or information listed below and bring to your first visit: Completed medical questionnaire. (Enclosed) Completed Notice of Privacy Practices (Enclosed). This form will allow us to discuss your care only with the authorized names you list, in accordance with Health Insurance Portability and Accountability Act (HIPAA). This form is also an acknowledgment that you have the opportunity to receive the Wagner Macula & Retina Center s Notice of Privacy Practices (NPP). Completed Information Regarding Dilating Eye Drops. (Enclosed) Drivers License or identification card and INSURANCE CARDS. List of your medications Referral - if your insurance requires one. Eyeglasses/Sunglasses. VIRGINIA BEACH NORFOLK CHESAPEAKE HAMPTON SUFFOLK KILMARNOCK, VA 317 VILLAGE ROAD, SUITE 102 VIRGINIA BEACH, VA RETINA FAX

2 On the day of your first visit, a technician will prepare you to see Dr. Wagner. During this process your eyes will be dilated. The dilating drops blur your vision and make your eyes sensitive to light for several hours. We encourage patients to bring someone to drive them home. Due to the dilation time and the nature of the examination, your visit may last approximately 2 hours. Please plan accordingly. If you are a diabetic, bring any necessary snacks. If you take medications on a routine time schedule, bring them with you. Due to the type of specialty, our practice encounters emergencies during the day and this may delay the time you are seen by the doctor. We will gladly file your insurance; however, be prepared to pay your copayment at the time of your visit. Payment arrangements can be made or we do offer a 30% discount to patients that pay in full on that date of service. (757) Due to limited seating, we respectfully request that you be accompanied by only one additional family member, friend or assistant. Should you have any further questions or concerns, please feel free to contact my staff at (757) **Two business days prior to your scheduled appointment you will receive an automated call reminding you of your appointment date, time and location. Sincerely, Alan L Wagner, M.D. & Staff Enclosures VIRGINIA BEACH NORFOLK CHESAPEAKE HAMPTON SUFFOLK KILMARNOCK, VA 317 VILLAGE ROAD, SUITE 102 VIRGINIA BEACH, VA RETINA FAX

3 WAGNER MACULA & RETINA CENTER For Office Use Only: Referral Date: First Appt Date Time Contact Person Physician: ALW Patient Name VB ORF KMK SSE SEP HRC CPK PATIENT INFORMATION DX: Street Address City State Zip Code Phone # Alternate# ( ) Single ( ) Married ( ) Widowed ( ) Divorced ( ) Separated Soc Sec No Date of Birth Age Sex Employer Address City, State, Zip Code Work Phone Occupation Job Title Spouse Name Spouse SS# Spouse Information Employer Address: Phone#: EMERGENCY CONTACT Name Relationship Phone Referring Physician: Phone#: Primary Insurance: Group#: ID#: Medical Doctor Address: Phone#: INSURANCE INFORMATION Secondary Insurance: Group#: ID#: ASSIGNMENT RELEASE I hereby authorize the release of medical information to my insurance company and agree that insurance benefits are to be paid directly to the physician. I understand that any insurance is a contract between me and the insurance company and that any filing on my behalf by the practice is done as a courtesy. I request that payment under Medicare Insurance Program be made on my behalf to the Retina and Vitreous Center, PC for any services furnished by that physician. I am financially responsible for all services. I agree to pay for all costs of collection, including an attorney s fee of 33 1/3% of the balance referred to the attorney in the event of default. (VB ORF KMK SSE SEP HRC CPK) FOR OFFICE USE ONLY APPLY ALLERGY Patient or Responsible Party Date LABEL HERE

4 WAGNER MACULA & RETINA CENTER Medical Questionnaire Name Date Do you have or have had any of the following medical problems? Circle Yes or No Diabetes Yes / No Year Diagnosed? High Blood Pressure Yes / No Year Diagnosed? Heart Condition Yes / No Year Diagnosed? Stroke Yes / No Year Diagnosed? Cancer Yes / No Year Diagnosed? Lung Disease/Asthma Yes / No Year Diagnosed? Skin Disease Yes / No Year Diagnosed? Bladder/Prostate Yes / No Year Diagnosed? HENT (head, ear, nose, throat) Yes / No Year Diagnosed? Tuberculosis Yes / No Year Diagnosed? Thyroid Yes / No Year Diagnosed? Gastrointestinal Yes / No Year Diagnosed? Neurological Yes / No Year Diagnosed? Hematologic/sickle cell/anemia/hiv Yes / No Year Diagnosed? Lymphatic/Lupus Yes / No Year Diagnosed? Muscle Skeletal/arthritis Yes / No Year Diagnosed? Do any members of your family (Mother/Father/Siblings etc.) have any of the medical conditions listed above? If so, list relationship and the condition. Have you ever been diagnosed with any eye diseases? If so, list diagnosis and year diagnosed. Does any family member have history of eye diseases? If so, list relationship and disease. Have you had any previous eye operations? If so, list type of operation and year. Have you had any previous operations? If so, list type of operation and year. Do you smoke? Yes / No Do you drink? Yes / No Do you exercise? Yes / No If so, how much? If so, how much? If so, how much? Do you use illicit substances/recreational drugs? Yes/ NO If so, what and how often? For Office Use Only Above History Reviewed by Rev 08/08

5 Rev 08/08

6 WAGNER MACULA & RETINA CENTER Medical Questionnaire Name Patient please complete: List Medications Dosage Reason for medication Date For Office use only: Technician initials/date Eye Drops/Ointment Dosage Reason for Medication MEDICATION ALLERGIES: FOOD ALLERGIES: Rev 08/08 MKH

7 Notice of Privacy Practices Wagner Macula & Retina Center The Wagner Macula & Retina Center (WMRC) recognizes that patient information is sensitive and, as such, must be treated carefully and responsibly. A federal regulation, know as HIPAA (Health Insurance Portability and Accountability Act) requires that we provide a detailed notice in writing of our privacy practices. It is the legal duty of WMRC to protect your health information from unauthorized use or disclosure while providing health care, obtaining payment for that health care and for other services relating to your health care. The purpose of this Notice of Privacy Practices is to inform you about how your health information may be used by WMRC, as well as reasons why your health information could be sent to other providers outside of our practice. The Notice of Privacy Practices describes your rights in regards to protection of your health information and how you may exercise those rights. It also gives you the names of contacts should you have questions or comments about the policies and procedures. There is a copy of the WMRC Notice of Privacy Practices available in the lobby for the patient or the patient s representative to review. You may also request a copy from the Practice. I (print your name) hereby authorize the discussion of my medical information and diagnosis including results regarding my care with the Wagner Macula & Retina Center with the following people. Name Relationship phone number Name Relationship phone number Name Relationship phone number Patient Acknowledgement I have received and/or had the opportunity to receive the Wagner Macula & Retina Center s Notice of Privacy Practices, which describes the methods for protecting my health information that is used in providing health care services to me. / Patient (or Personal Representative) Date / Witness Date Note: WMRC retains this signed page

8 Name: Date of Birth: INFORMATION REGARDING DILATING EYE DROPS Dilating 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, it s best if you make arrangements not to drive yourself. Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention. I hereby authorize Dr. and/or such assistants as may be designated by them to administer dilating eye drops. The eye drops are necessary to diagnose my condition. Patient (or person authorized to sign for patient) Date Witness Date

9 Enrollment Form For JETREA (ocriplasmin) And Patient Assistance To initiate patient benefit verification process please complete and submit enrollment form by fax ( ), online at JETREACARE.com, or mail to: ATTN: JETREA CARE, 6900 Dallas Parkway, Suite 200, Plano, TX Your patient may also choose to investigate eligibility for the patient assistance programs by completing this form (please see page 2). JETREA CARE Coordinators can be reached at to answer general questions Monday through Friday from 7:00 am to 7:00 pm CST, or you can visit our online resource, JETREACARE.com Office Portal Registration (please complete section D and submit via Fax or RBM) A. Patient And Insurance Information (Required) Patient Medical Record #: Site of Service: Physician Office Hospital / ASC Patient s First Name: Middle Initial: Last: Date of Birth: Sex: M F Street Address: SSN: - - Primary Language: City: State: ZIP: US/Puerto Rico Resident: Yes No Primary Phone #: ( ) Secondary Phone #: ( ) Address: Primary Insurance Plan: Medicare Commercial/Private Medicaid Other Policy Holder s Name: Policy Holder s Date of Birth: Primary Insurance Plan information may be provided by completing the below OR attaching a front/back photocopy of Insurance Plan Card. Please indicate if attached: Yes No Insurance Plan Name: Phone #: ( ) Employer: Policy ID #: Group ID #: Health Insurance Plan Name: B. Information For Diagnosis (ICD-9) (Required) ICD-9 Code: Affected Eye: Right Eye Left Eye Diagnosis Date: C. Prescription (Rx) Product Name: JETREA (ocriplasmin) Intravitreal Injection, 2.5 mg/ml Dosage: mg Preferred Specialty Pharmacy: Prescriber Signature: Date: Secondary Insurance Plan: Medicare Commercial/Private Medicaid Other Policy Holder s Name: Policy Holder s Date of Birth: Secondary Insurance Plan information may be provided by completing the below OR attaching a front/back photocopy of Insurance Plan Card. Please indicate if attached: Yes No Insurance Plan Name: Phone #: ( ) Employer: Policy ID #: Group ID #: Health Insurance Plan Name: D. Prescribing Physician Information And Physician Enrollment Certification (Required) Prescriber Name & Title: State License #: Tax ID #: Site/Facility Name: Medicaid/Medicare Provider #: NPI #: Street Address: City: State: ZIP: Office Contact Name: Office Phone #: ( ) Office Fax #: ( ) Office Address: Please use office fax number and for best receiving results I verify the information I have provided in the enrollment form is complete and accurate to the best of my knowledge. I have obtained patient s authorization, as indicated below, to disclose your health information related to the treatment with JETREA to ThromboGenics and its authorized JETREA CARE agents to use and disclose as necessary in the provision of health services or to offer patient care and support services and/or reimbursement support services. Prescriber Signature: Date: E. Patient Authorization For Use/Disclosure Of Health Information (Required) I authorize my prescribing physician and any health insurers, plans, or programs that provide me health care benefits (collectively, Health Plans ) to disclose my medical or other information, including information about my treatment with JETREA, ThromboGenics and its authorized JETREA CARE agents so that ThromboGenics may use and disclose the Information for the following specific purposes: ordering, manufacturing, delivering, and injection of JETREA. ThromboGenics obtaining payment from my Health Plan(s); conducting reimbursement verification; applying for or making referrals for Co-pay Assistance upon request; and providing me with educational and treatment support services by mail, , and/or telephone. I understand that, once my Information has been disclosed to ThromboGenics, federal and state privacy laws may no longer protect it. However, ThromboGenics agrees to protect my information by using it only for the purposes authorized in this Authorization or as permitted by law. I understand that signing this Authorization is voluntary and, if I do not sign the Authorization, it will not affect my ability to obtain treatment from my prescribing physician or obtain insurance or insurance benefits. I understand, however, that if I do not sign this Authorization, I will not be eligible to receive services and Co-pay Assistance. I may withdraw this Authorization at any time by faxing a written request to JETREA CARE at or by mailing to JETREA CARE, 6900 Dallas Parkway, Suite 200 Plan, TX Withdrawal of this Authorization will end further uses and disclosures of my Information by the parties identified in this Authorization, except to the extent those uses and disclosures have been made in reliance upon this Authorization and as permitted by applicable law. This Authorization expires 10 years from the date indicated below unless I withdraw it earlier. I am entitled to receive a copy of this Authorization. Patient/Guardian Signature: Date: Please fax completed enrollment form to JETREA CARE ( ); mail to ATTN: JETREA CARE, 6900 Dallas Parkway, Suite 200, Plano, TX (ocriplasmin) Intravitreal Injection, 2.5 mg/ml C A R E

10 Patient Assistance Eligibility And Enrollment Application F. Patients Insured Through Government Programs (Eg, Medicare) Please select if you are interested in having your eligibility reviewed for Co-pay Assistance. Please indicate your household adjusted gross income: Medicare co-pay foundations provide assistance regardless of the choice of medicine, and decisions are based on financial need and according to criteria established by individual foundations. ThromboGenics can assist patients by referring them to these independent organizations. ThromboGenics cannot guarantee that patients will be eligible for or receive assistance after referral. ThromboGenics does not have controlling or managerial influence on these independent organizations. G. Patients Insured Through Commercial Insurance Plans (Signatures Required) Please select if you are interested in the JETREA CARE Co-pay Program. JETREA CARE supports eligible patients with private commercial (non-government payers) insurance by covering any combination of cost (co-pay, co-insurance, and/or deductible). You may be eligible for the JETREA CARE Co-pay Program if: Your annual household adjusted gross income is $100,000 or less: Yes No Please indicate your household adjusted gross income: Number of household members: Patient Attestation: I verify that the information that I have provided to enroll in the JETREA CARE Co-pay Program is complete and accurate to the best of my knowledge. I agree that, if I am requested, I will provide proof of income or any other eligibility requirement in a timely manner. Patient Signature: Date: Physician Attestation: By participating in the program, I agree that I will not submit any third-party claims for patient cost-sharing expenses (including copay, deductibles, and/or co-insurance) that are covered by the JETREA CARE Co-pay Program. I also agree that I will disclose my participation in the Co-pay Program to third-party payers as required. In addition, I certify that my participation in this program is consistent with my obligations as a participating provider with any third-party payers. Prescriber Signature: Date: H. Uninsured Patients You may be eligible for the patient assistance program if you have no health insurance, including if you do not have drug coverage due to a drug benefit carve-out, or are rendered uninsured due to a payer claim denial. Your annual household adjusted gross income is $100,000 or less: Yes No Income documentation is attached* (1040, 1040EZ, IRS-W2, SSI Letter, SSDI, or Letter of Income): Yes No *Income documentation and residency verification will be required for this program. I. Patient And Physician Certification (Only Required If Patient Is Uninsured At The Time Of Enrollment And Is Applying To Receive JETREA (ocriplasmin) Free Of Charge) I would like to receive JETREA at no charge under the JETREA CARE underinsured patient program. I understand that all the information I provide in connection with this application will be used to determine my eligibility to participate in the program. I certify that I do not have coverage for prescription drugs under Medicare, Medicaid, or other public or private insurance plan, or that it has been determined that I am functionally uninsured. I understand that ThromboGenics, the manufacturer of JETREA, reserves the right to modify the eligibility requirements or discontinue the program at any time. I hereby certify the accuracy of the information submitted on, and in connection with, this application. I acknowledge that ThromboGenics has the right pursuant to my authorization for use/disclosure of health information to verify my eligibility for the JETREA CARE patient assistance program, to audit reported financial income and insurance information and medical records, and to contact me directly to confirm receipt of JETREA. Patient Signature: Date: My signature below certifies that the person named on this form is my patient, the information provided on the application is complete and accurate, and the JETREA received in response to this application is only for the approved indicated use of JETREA for the patient named on this form. I acknowledge that this medication will not be offered for sale, and no claim for reimbursement of either JETREA or related medical procedures and services will be submitted to Medicare, Medicaid, or any third-party payer. I understand that ThromboGenics and JETREA CARE agents have the right to contact my patient directly to confirm receipt of JETREA and that ThromboGenics may revise, change, or terminate this program at any time. Prescriber Signature: Date: J. Patient Acknowledgement (Required For All Programs) By signing this form, I acknowledge that all eligibility information provided is accurate to the best of my knowledge. I acknowledge that by indicating I am interested in any patient assistance program described above, ThromboGenics may provide the information included on this form to the independent foundations that manage the patient assistance programs pursuant to my authorization for use/disclosure of health information. Patient Signature: Date: Patient s Full Name (please print): Date of Birth: Please fax completed enrollment form to JETREA CARE ( ); mail to ATTN: JETREA CARE, 6900 Dallas Parkway, Suite 200, Plano, TX JETREA CARE and JETREA CARE logo are trademarks or registered trademarks of ThromboGenics NV in the United States. (ocriplasmin) Intravitreal Injection, 2.5 mg/ml C A R E

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14 PATIENT AUTHORIZATION AND NOTICE OF RELEASE OF INFORMATION (PAN) Phone: (866) Fax: (866) Genentech-Access.com/LUCENTIS LUCENTIS Access Solutions is a free program for you from Genentech. We work to help you pay for your LUCENTIS (ranibizumab injection). We can help in many different ways. We assist people who have a health care plan as well as those who don t. If you don t have a health care plan, or your plan won t pay for your LUCENTIS, we might be able to help. If you meet certain financial and medical standards, we can supply free medicine. This is done through the Genentech Access to Care Foundation (GATCF). For us to help, we need to look at, use and disclose your personal health information (PHI). Your doctor and health care plan may disclose your PHI to us only with your written consent. Once you sign this form and it is sent back to us or submitted electronically by your doctor, we can start to provide these services. We can provide you with a copy of this Release. You need to ask us for this first before we can send the copy back to you. You do not have to agree to this Release. But we cannot provide our services without it. This means you might need to pay for certain medicines on your own. PLEASE READ THROUGH THIS FORM CAREFULLY. IF YOU HAVE ANY QUESTIONS, TALK TO YOUR DOCTOR S OFFICE OR CALL US AT THE PHONE NUMBER LISTED AT THE TOP OF THIS PAGE. 1. Information to Be Disclosed or Used This signed form lets my doctors and health care plans send my PHI and this form electronically to LUCENTIS Access Solutions and/or GATCF. This includes: All my health records relating to my treatment Information about my health care plan benefits The dollar balance left on the total of the lifetime payments covered by my health care plan policy (if this applies to my plan) Any information having a bearing on my health or my adherence to my treatment All of the above is considered part of my PHI. I know this could include information about: Sexually transmitted diseases Mental health conditions Genetic test results We are not looking for this information. It might be part of the medical record sent to us. 1/3

15 PATIENT AUTHORIZATION AND NOTICE OF RELEASE OF INFORMATION (PAN) Phone: (866) Fax: (866) Genentech-Access.com/LUCENTIS 2. Who May See and Use My Personal Health Information (PHI) My PHI may be seen by LUCENTIS Access Solutions and/or GATCF. These are programs sponsored by Genentech. Its address is 1 DNA Way, Mail Stop #858a, South San Francisco, CA It may also be seen by anyone helping LUCENTIS Access Solutions perform services. My PHI may be used only in these ways: Helping with my health care plan coverage for LUCENTIS (ranibizumab injection) Applying to GATCF Tracking my use of LUCENTIS For Genentech administrative purposes 3. Expiration Date This Release is in effect for 1 year once I have signed it. I may also withdraw it in writing at any time. 4. Notices Once I sign this form, I know my PHI might not be covered by any federal law about the use of my PHI or how it is disclosed. There is no guarantee my PHI might not be released to a third party. This third party might not need to follow the conditions of this Release. I know I can refuse to sign this form. I may withdraw it at any time and for any reason. This won t affect the start or continuing of my treatment. It will have no effect on the quality of my treatment. I know this Release stays in effect for 1 year or until I withdraw it in writing. To withdraw it, I must send a written notice to Genentech. It can be sent by fax or by mail to the address at the bottom of this page. This withdrawal goes into effect once it is received by Genentech. It will have no impact on my treatment by my doctor. If I don t sign this form or withdraw it, I may be responsible for the costs of my treatment. 5. Distribution Acceptance If I receive free product from GATCF, I will use LUCENTIS as my doctor has prescribed it to me. I will not sell or distribute LUCENTIS. I understand it is unlawful to do this. I am responsible for ensuring LUCENTIS is sent to a secure address when it is shipped to me. I know it is my duty to control LUCENTIS while it stays in my possession. Section 6 on the next page is required. This written notice must be signed, dated and mailed or faxed to: LUCENTIS Access Solutions 1 DNA Way, Mail Stop #858a South San Francisco, CA Fax: (866) /3

16 PATIENT AUTHORIZATION AND NOTICE OF RELEASE OF INFORMATION (PAN) LUCENTIS Access Solutions You must sign and date here 6. Signature and Date (Required) You must print patient s name here I have read and understand the terms of this Release form. I have had the chance to ask questions about the use of my personal health information (PHI) and who may see it. By signing this form below, I know I am releasing my PHI as discussed in this form. (Please fill in all information below. Be sure to sign and date this form. If you don t, it could hold up the process for helping you.) Signature of Patient or Guardian* Relationship to Patient Date Print Patient s Name Alternate Contact Name Patient Address *If Guardian is signing, please provide Power of Attorney documents. Alternate Contact Phone 7. Financial Information Sign and date here (if needed) Fill out this section only if you want to apply for help from GATCF. Household Adjusted Gross Income: $0-$25,000/yr $25,001-$50,000/yr $50,001-$75,000/yr $75,001-$100,000/yr Other: I know that to qualify for free medicine, my household adjusted gross income may not be more than $100,000 per year. I certify the above statement of my income for last year is true. I do not have the financial resources to pay for LUCENTIS. I agree to give GATCF proof of my income. This may be a copy of my IRS 1040 form from last year. It may be other proof of my income as well. I will send this to GATCF within 45 days after this form is submitted. I know if I fail to supply this, GATCF won t be able to keep helping me. Signature of Patient or Alternate Contact Date 8. An Optional and Free Patient Support Program I want to enroll in an optional and free patient support program from Genentech. I understand my PHI is needed for me to be a part of this program. I also know my PHI will be shared with LUCENTIS Access Solutions and the patient support program. I may choose to be contacted by mail, or phone. I understand my PHI won t be shared outside of Genentech or by its agents. I agree to let Genentech or its agents contact me in the future about this program. The Genentech privacy policy can be found at Genentech-Access.com/LUCENTIS. I understand I do not have to sign this part of the form. It plays no role in getting my medicine. It is not part of receiving help from LUCENTIS Access Solutions. I also know I may cancel this enrollment in the patient support program at any time. To cancel, I can call (877) Preferred way to contact me (Please check the boxes that apply and fill in your information. You can check more than one box.): Phone Number: Okay to leave a message? Yes No Address: Choose to enroll by signing here Signature of Patient (you must sign here to enroll in the patient support program). Date LUCENTIS, its logo and the Access Solutions logo are registered trademarks of Genentech, Inc Genentech USA, Inc. So. San Francisco, CA All rights reserved. ACS /12 Printed in USA on E recycled paper 3/3