Florida Eye Center Patient Registration Form (Please Print Clearly)

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1 Florida Eye Center Patient Registration Form (Please Print Clearly) Personal Information Legal Name: Last First MI Suffix Nickname: Social Security: - - Drivers License # Date of Birth: / / Mailing Address: Apt # City: State: Zip Code: Home: ( ) Work: ( ) Cell: ( ) Ethnicity: Asian African American Caucasian Hispanic Other Marital Status: Married Divorced Single Widowed Other Primary Care Physician: Phone: ( ) Specialist: Phone: ( ) Insurance Information **We need all information requested to properly file your insurance Responsible/Primary Insured Party Name: (person) D.O.B / / Relationship: Social Security # / / Address: (if different from above) City: State: Zip Code: Phone: ( ) Vision Insurance: Eyemed VSP Superior Vision Insured Name Social Security: - - (this is NECESSARY to properly file any vision insurance) Primary Medical Insurance: _ Insurance Address (see back of card) Policy/Subscriber # _ Group # Specialist Co-Pay (we are considered specialist) Secondary Medical Insurance: Insurance Address (see back of card): Policy/Subscriber # Group # Specialist Co-Pay (we are considered specialist) Emergency Contact: Phone: ( ) Patient Secondary Phone: ( ) I hereby attest that all information is correct to the best of my knowledge. Date: Signature:

2 Florida Eye Center FAMILY RELEASE FORM I _ give permission for the staff at Florida Eye Center to speak to the following family and/or friends regarding my health issues. Relationship Relationship Relationship Relationship I understand that the people on this list will be the only people to receive my health information. I understand that medical records are not included in this consent. I may update this list at any time. Patient Signature Date

3 Name Date Medical/Ocular History Past Ocular History: Yes No Yes No None/ unremarkable Dry eyes Cataracts Amblyopia/lazy eye Glaucoma Surgery/Other: Macular Degeneration Retinal tear/ detachment Past Medical/ Surgical History: Yes No Yes No None/ unremarkable Cancer (type: ) High blood pressure Heart disease Diabetes: Type 1/ Type 2 Surgeries/Other: High cholesterol Thyroid (hypo/ hyper) Medications: (Including vitamins): Allergies to medications: Family Ocular/ Medical History: Yes No Yes No None/ unremarkable Cataract Diabetes Hypertension Glaucoma Macular Degeneration Amblyopia/ lazy eye Retinal detachment Blindness Other: Social History: Alcohol use: Tobacco use: None Moderate None Type: Mild Heavy Frequency/ Amount: Patient Signature Physician Signature

4 Name Date Review of Systems: Do you have these now? If so, circle condition and explain. Yes No Allergy: Seasonal/year round Cardiovascular: High/low blood pressure/ chest pain/ irregular beat Constitutional: Fever/weight change/fatigue Endocrine: High sugar/ High thyroid/ low thyroid ENT: Hearing loss/ sinus Eye: Blurred vision/ eye pain/ flashes/ floaters GI: Abdominal pain/ nausea/ vomiting/ diarrhea GU: FLOMAX use/ groin pain/ sores Blood: Anemia/ easy bruising/ swollen lymph nodes Skin: Rashes/ changing moles/ eczema Musculoskeletal: Joint pain/ weakness/ back pain Neurological: Headache/ scalp tenderness/ jaw pain Psychiatric: Anxiety/ depression Respiratory: Shortness of breath/ Sleep apnea/ CPAP Patient Signature Physician Signature

5 Medical Records / Insurance Authorization and Assignment I hereby authorize Florida Eye Center to furnish all information to insurance carriers, doctors and hospitals concerning my illness, treatments, and I hereby assign to the physician(s) all payments for medical services rendered to my dependents or myself. I understand that Florida Eye Center is required to protect the privacy of my health information. Florida Eye Center has their privacy notice posted in the waiting area and they can furnish a copy of the notice at my visit if I request to have one in writing. I understand that I am responsible for any amount not covered by insurance; this includes any course treatment that is not a covered benefit (this includes HMO products). I understand that I am responsible for notifying Florida Eye Center of any change in my insurance coverage, if I am delinquent in updating this information and the charges are denied, I understand that I will be held responsible for these charges. I acknowledge that I will only receive a bill if my balance exceeds $3.00, and I will only receive a refund if the credit amount is over $10.00; otherwise either will be resolved at subsequent visits. I agree and understand that if my account is turned over to a collection agency, I am responsible for any cost incurred in collection of said balance, which may include up to a 50% increase on the original balance. I have read and understand the above and agree to comply. Date: Signature: Parent/Guardian signature and relationship:

6 Cancellation Policy I am aware that Florida Eye Center has a 24-hour notice of cancellation policy. There will be a $25.00 charge billed to my account that is non-covered by my insurance. As the patient I will bear complete financial responsibility for this fee. * Repeated missed appointments may result in dismissal from our practice. Thank you for understanding. Date: Signature: Parent / Guardian signature and relationship: Routine Eye Care Information Certain insurance companies do not pay for routine eye exams. Some patients have Normal Eye Exam or Refractive Error. These are not always a covered benefit. The physicians will always document findings in the chart and disclose to the insurance company if there is a medical condition, which would be covered by insurance. Signature is required below so there is not confusion about who will be responsible for the bill. If your company denies coverage then the patient is responsible. Date: Signature: Parent / Guardian signature and relationship:

7 Florida Eye Center- Privacy Notice update 8/2013 This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully 1. How we may use and disclose your health information. We use health information about you for treatment, to get paid for treatment, for the administrative purposes, and to evaluate the quality of care that you receive. For example, your health information may be shared with other providers to whom you are referred. Information May be shared by paper, mail, electronic mail, fax and other methods. We may use or disclose your health information without your authorization for several reasons. But beyond those situations, we will ask for your written authorization before using or disclosing your health information, you can later revoke it stop any future uses and disclosures. 2. Your rights. In most cases, you have the right to look at or get a copy of your health information that we use to make decisions about you. If you request copies, we may charge you a cost based fee. You also have the right to request a list of certain types of disclosures of our information that we made. If you believe your health information is incorrect or information is missing, you have the right to request that we correct the existing information or add the missing information. 3. Marketing: We may use or disclose your health information to make a marketing communication to you that occurs in a face to face encounter with us or which concerns a promotional gift or nominal value provided by us. Certain Marketing Purposes: If we receive financial remuneration in exchange for making a marketing communication we must obtain your Authorization for any use or disclosure of Health Information other than face to face communication made by us to you, or for a promotional gift of nominal value provided by us. We will continue contacting you via telephone, mail, fax or in regard to your appointments, service and new products 4. Our legal Duty. We are required by law to protect the privacy of your health information, provide the notice about our privacy practices, follow privacy practices that are described in this notice, and seek your acknowledgment of receipt of this notice. We may change our privacy policies at any time. Before we make a significant change in our policies, we well change our notice. For more information about our privacy policies, contact the person below. 5. Privacy complaints. If you are concerned that we have violated your privacy right, or policies, or if you disagree with a decision we made about access to your health information, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person below can provide you with the appropriate address upon request. If you have any questions or complaints, please contact Stephanie N. 46 th Street, Tampa, FL or Please sign and print your name and provide the date below to acknowledge that you have received this notice of Privacy Practices. Signature Print name Date

8 Florida Eye Center s Refraction Policy What is Refraction? Refraction is the process of determining the eye s focusing ability, or need for corrective glasses and/or contact lenses. Why is it sometimes necessary? Refractions are sometimes necessary depending on the patient s diagnosis and/or complaints presented. Refraction is also necessary to prove to insurance companies the need for cataract surgery. We must prove that your vision cannot be simply improved with eyeglass prescription. As you can see, refraction is an essential part of an exam; however Medicare and most insurance companies DO NOT cover the charge for the refraction. Will I be notified in advance if I need it? Yes, only the doctor or technician is qualified to tell you if this procedure is necessary. You will be given the option to decline this service. It is important to understand that if you decline, we may not be able to determine the cause for the change in your vision. How much is the procedure? Our office policy is to charge $ for this procedure in addition to the office visit copay and / or deductible. Payment is due at the time services and rendered. We will bill your insurance according to the individual contracted fee schedules. If your insurance pays the fee we will gladly refund you this prepaid amount once we receive payment from your insurance company. NOTE: This fee is due at the end of your visit; and payable whether or not you receive a written prescription. Sometimes the change in vision is not significant to warrant the cost of purchasing new glasses. However, the fee covers the doctors and technician s time and effort in achieving this process. ACKNOWLEDGEMENT: I have read the above information and understand that the refraction is a non-covered service. I accept full financial responsibility for the cost of the service. Patient Signature (Parent s signature for minor) Print Patient Name Date: / /

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