Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous com

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1 Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous com 1 Calvin E. Mein, MD 9480 Huebner Rd, Suite 310 (210) Moises A. Chica, MD San Antonio, Tx Fax (210) R. Gary Lane, MD For Office Use: Pt ID#: PATIENT INFORMATION FORM Welcome to our office! The following information is used for our records and for insurance purposes. Please be as accurate as possible. Thank you for your cooperation. Today s Date: Patient Name: (Last) (First) (Middle) Male Female Date of Birth: Social Security Number: ( ) Child ( ) Single ( ) Married ( ) Divorced ( ) Widowed Mailing Address: _ City: State: (Number & Street) Zip: Home Phone: ( ) Cell Phone: ( ) Employer: Work Phone: ( ) Occupation: Family Physician: Phone: ( ) (Mandatory if you are Diabetic) Who should we contact in an emergency? Phone: ( ) Referred By: ( ) Doctor: Phone: ( ) ( ) Other: Phone: ( )

2 2 INSURANCE INFORMATION Name of Primary Insurance Company: Secondary Insurance Company: Insured Name: Social Security # Insured Employer: Phone Number: Insured s Date of Birth: Relationship to the Patient: ( ) Spouse ( ) Mother ( ) Father ( ) Other: ( ) Medicare # ( ) Medicaid # _ ( ) Workers Comp ( ) DARS Counselor s Name: Phone # Insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment to the doctor. Some companies pay fixed allowances for certain procedures, and others pay as percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance. To the extent necessary to determine liability for payment and to obtain reimbursement, I authorize disclosure of portions of the patient s record. I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, Medicaid, private insurance, and other health plans to Retinal Consultants of San Antonio, P.A. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as a valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment. Responsible party: X Date: / / Month Day Year **You will be dilated today. After your exam your vision may be blurry. Please do not drive while your eyes are dilated. We recommend someone drive you home. There is a phone in the waiting area for you to call for a ride

3 3 HEALTH HISTORY FORM Name: Date: Describe in your own words why you are seeing us today. Please list any vision problems you are having: IS THIS RELATED TO AN EYE INJURY? YES NO ALLERGIES: Are you allergic to any medications? (Yes/No) If yes, please list them: MEDICATIONS: List all medications (including eye drops) you are currently using: EYE HISTORY- Have you been diagnosed with any of the following? Yes No Yes No [ ] [ ] Retinal Detachment [ ] [ ] Cataracts [ ] [ ] Macular Degeneration [ ] [ ] Glaucoma [ ] [ ] Iritis [ ] [ ] Eye Injury [ ] [ ] Diabetic Retinopathy [ ] [ ] Vitreous Hemorrhage Cataract surgery (date of surgery) Right Left Other eye surgery (please include dates) MEDICAL HISTORY- Have you been diagnosed with any of the following? [ ] Asthma [ ] Kidney Disease [ ] Cancer [ ] Migraines [ ] Carotid artery disease [ ] Thyroid Disease [ ] Diabetes # of years [ ] Rheumatoid arthritis [ ] Head or spinal injury [ ] (Women) Are you pregnant? [ ] Heart disease [ ] Anemia [ ] High Blood Pressure [ ] Other: Please continue on the next page

4 4 PLEASE LIST ALL OTHER SURGERIES: SOCIAL HISTORY: Do you smoke? Yes or No Do you currently drink Alcohol? Yes or No Do you currently drive? Yes or No. Do you have any restrictions? FAMILY HISTORY Has anyone in your family (blood relative) had any of the following? Please put a letter next to the appropriate box. F- Father M- Mother S-Sister B-Brother A-Aunt U-Uncle MGM- Maternal Grandmother PGM- Paternal Grandmother MGF- Maternal Grandfather PGF- Paternal Grandfather [ ] Amblyopia [ ] Macular Degeneration [ ] Blindness [ ] Retinal Detachment [ ] Cataracts [ ] Cancer [ ] Crossed Eyes [ ] Diabetes [ ] Diabetic Retinopathy [ ] Heart Disease [ ] Glaucoma [ ] High Blood Pressure [ ] Stroke [ ] Other: Signature of Patient or Guardian Date

5 5 PATIENT CONSENT FORM Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA). The patient understands that: Protected health information may be disclosed or used for treatment, payment or health care operations. The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice. The Practice reserves the right to change the Notice of Privacy Policies. The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions. The patient may revoke this Consent in writing at any time and all future disclosures will then cease. The Practice may condition treatment upon the execution of this Consent. The federal privacy laws now limit our ability to communicate with your family and others who may participate in your medical care. Please list those individuals with whom you would allow us to share your health information, if necessary. Name Name Relationship Relationship Patient s Signature Date: Print Patient s Name Relationship to Patient (if other than self) Signed in front of (Printed name of Practice Employee)

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary. Today s : Are you here for an injury that is work-related? YES NO N/A Patient Name (First-Middle-Last)

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