INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION

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1 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 Native, Asian, Black or African American, White or Caucasian, Hispanic or Latino, Native Hawaiian or Other Pacific Islander, Native American, Other: PREFERRED LANGUAGE (please circle): English, Spanish, Navajo, German, French, Other: MANDATORY PERSON TO CONTACT IN CASE OF EMERGENCY: NAME RELATIONSHIP PHONE REFERRING DR PHONE PRIMARY CARE DR: INSURANCE INFORMATION PHONE PRIMARY INSURANCE COMPANY SECONDARY INSURANCE COMPANY (COMPLETE INFORMATION BELOW IF OTHER THAN YOURSELF) PRIMARY CARDHOLDER S NAME/RELATIONSHIP DOB SOCIAL SECURITY # SECONDARY CARDHOLDER S NAME/RELATIONSHIP DOB SOCIAL SECURITY # FINANCIAL AGREEMENT The financial policy of the practice has been fully explained to me and I acknowledge full responsibility for all charges incurred including any additional charges incurred in the collection of this account, if my insurance later determines my services to be noncovered or not a benefit. PATIENT SIGNATURE: X DATE EMPLOYEE WITNESS DATE PRIVACY POLICY (HIPAA) I understand that HIPAA has implemented procedures that require specific authorization for release of my information. I agree to the following statements and understand that I can revoke these at any time by informing the Privacy Officer in writing. Home telephone #: We may leave a message with a callback number or appt reminder on voic . Written communication: We may mail postcards to your home address or send you an . I have received the NOTICE OF PRIVACY PRACTICES and I have been provided an opportunity to review it. I understand that the last four digits of my social security number will be used as a password to identify persons seeking information regarding my health care, e.g. for test results, prescription refills, billing info. If I would like a different code assigned, I will list it here:. I will give this code to my family members or friends who may need to call the practice on my behalf. Without this code the physicians or staff members will not be able to speak with anyone except myself. PATIENT SIGNATURE: X DATE LIFETIME INSURANCE AUTHORIZATION I authorize and request that payments under my medical insurance programs be made directly to pay the provider for any services furnished to me. I also authorize the provider to release any information needed for payment of claims. I further permit copies of this authorization to be used in place of the original. PATIENT SIGNATURE: X DATE

2 RETINAL CONSULTANTS OF AZ, LTD. 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 the physicians of Retinal Consultants of Arizona and/or such assistants as may be designated by him/her to administer dilating eye drops. The eye drops are necessary to diagnose and provide ongoing treatment for my condition. Patient Signature (or person authorized to sign for patient) Date Patient Name (Please Print) Date of Birth Witness Date

3 MEDICAL HISTORY QUESTIONNAIRE Patient: Date: Date of Birth: / / Occupation: Date of last eye exam: List any medications (including eye drops) you currently take (prescription and over-the-counter): Do you have allergies to any medications? YES NO Latex Allergy? YES NO Iodine Allergy? YES NO If YES, list the medications: List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc): List any surgeries (including eye surgeries) you have had: Do you currently have any problems in the following areas? If YES, please circle all that apply and write in any additional. GENERAL / CONSTITUTIONAL (fever, heat stroke, weight loss, weight gain, unusually tired) EARS, NOSE, THROAT (hard of hearing, stuffy nose, earache, cough, dry mouth, etc.) RESPIRATORY (congestion, wheezing, short of breath, etc.) CARDIOVASCULAR (high BP, racing pulse, etc.) GASTROINTESTINAL (stomach upset, diarrhea, constipation, hernia, ulcers, etc.) GENITAL, KIDNEY, BLADDER (painful urination, frequent urination, impotence, yellow jaundice, etc.) SKIN (pimples, warts, growths, rash, etc.) ENDOCRINE (Diabetes Type I or Type II, hypothyroid, etc.) NEUROLOGICAL (numbness, headache, seizures, paralysis, etc.) PSYCHIATRIC (anxiety, depression, insomnia) MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling, cramps, arthritis, etc.) BLOOD / LYMPH (bleeding, cholesterolemia, anemia, problems related to blood transfusion, etc.) ALLERGIC / IMMUNOLOGIC (sneezing, swelling, redness, itching, hives, lupus, etc.) FEMALES Are you pregnant? Nursing? EYES (poor vision, eye pain, tearing, redness, etc.) FAMILY HISTORY YES NO Details Has any member of your family had these diseases (circle all that apply)? YES NO UNKNOWN (Mother, Father, Grandparent, Sibling) Arthritis, Blindness, Cancer, Cataract, Diabetes, Glaucoma, Heart Disease, Hypertension, Macular Degeneration, Stroke, Thyroid Disease Other heritable disease: SOCIAL HISTORY Does your vision limit any activities of daily living (driving, reading, sports, work, other )? Have you ever had a blood transfusion? Y N If YES, how much? Do you drink alcohol? Y N If YES, how much? Do you smoke? Y N If YES, how much? How many years? Patient signature: Date: Physician s signature: Date: Medhx/0408R/0408P PHARMACY: CROSS STREETS: PHONE NUMBER:

4

5 CONFIDENTIAL Authorization for Disclosure of Protected Health Information (Medical Records Release) In order to provide for your healthcare, our practice collects information about your medical history, physical examinations, test results, diagnoses, and treatments. Use and disclosure of protected health information is regulated by a federal law known as The Health Insurance Portability and Accountability Act of 1996 ("HIPAA"). Under HIPAA, healthcare providers must obtain a valid authorization in order to release any such information to a third party for purposes not related to your treatment, receiving payment, or healthcare operations. This authorization gives our practice permission to disclose the elements of your protected health information listed below for the specified purposes to the stated recipient. I understand that I do not have to sign this authorization to get health care benefits (treatment, payment or enrollment), except: to take part in a research study; or to receive health care when the purpose is to create health information for a third party. I understand that I may revoke this authorization in writing at any time. However, I understand that a revocation is not effective to the extent that my physician has relied on the use or disclosure of health information or if the authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest the claim. I understand that there is a charge of $5.00 for records exceeding 25 pages to assist with administrative costs, if I request records to be sent to myself. Patient: DOB: Last 4 digits of SS #: Address: City/State/Zip: I, consent to the disclosure of the following information: G Dictated notes G MRI G Telephone call forms G Fundus photos G Office notes G Lab reports G Billing history G Visual fields G Fluorescein angiography G Electrocardiograms G All clinic records G Other (specify) For the following dates: G Since G All Records I hereby give special permission to release otherwise privileged information pertaining to the following: G Mental Health G AIDS Test results G Alcoholism G Developmental disabilities G AIDS-Related disease diagnosis G Drug abuse Purpose or need for disclosure: G At the request of the individual G Application for insurance G Further medical care G Payment of insurance claim G Legal investigation G Employer update G Vocational rehabilitation evaluation G Disability determination Release Record(s) To The Following: Address: City/State/Zip: Phone #: Fax #: Comments: Phys. Approval Privacy Officer Date Records copied by: Faxed or mailed by: Date: Medrecords (10/06) Blue: Privacy Officer Pink: Send with records or send to patient Green: Chart

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