Maryland Vision Institute

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1 Maryland Vision Institute Any information we already have is displayed. Please review and complete all to ensure that the information we have is correct and current. Patient Info: Date Record Printed: Account Number: Patient Name: Date of Birth: Sex: M / F Social Security #: Address: City, State, Zip: Home Phone Number : Cell Phone Number : Daytime Phone Number : How did you hear about us?: Marital Status (circle): S=Single M=Married D=Divorced X=Separated W=Widowed U=Unknown Patient Employer: Primary Care Physician & Phone# (if known): Optometrist & Phone# (if known): Optical Shop (include location) & Phone #: Pharmacy (include location) & Phone# (if known): In Case of Emergency Contact: Name: Phone: Update Financially Responsible and/or Insured Party - If Different than Patient Responsible Party NAME: Insured Date of Birth: Address: State: Zip: C INSURANCE CARRIER INSURED INSURED ID GROUPID DOB RELATION = ==================== ================== ================ ========== ========== ======== I have reviewed the above, made corrections and agree to its completeness. Signature Date

2 MARYLAND VISION INSTITUTE also Billing for PHYSICIAN'S SURGERY CENTER Please review and sign at the bottom. Patient Name: Date of Birth: Acct #: In order to control the cost of billing, we ask that the patient's portion of their bill be paid at the time of service. We are required to collect your copayment, refraction fee $30.00, contact lens fitting fee can range from $30.00 to $200.00, and all other fees at the time of service. If you are unable to pay your Copayment or Refraction fee today, we will be able to bill you for an additional $10.00 fee. Any request for record releases there will be a charge of $10.00 up to the first 50 pages, and.10 cent for each additional page. The undersigned will ultimately be responsible for any bill incurred in this office or at Physician's Surgery Center regardless of insurance. I understand that it is my responsibility to obtain a referral if necessary for payment. Accounts 90 days or older are subject to collection fees. There will be a $25.00 service charge on all returned checks. Payment from my insurance is to be paid directly to Maryland Vision Institute and/or Physician's Surgery Center. I understand that billing any secondary insurance is ultimately my responsibility, however, Maryland Vision Institute and/or Physician's Surgery Center routinely will submit to these Plans if they are able. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when a claim is processed. I authorize Maryland Vision Institute and/or Physician's Surgery Center to release any information, including diagnosis and the records of any treatment or examination to third party payers and/or health practitioners. Often my eye doctor will find it necessary to dilate my pupils during my exam. Dilating drops frequently blur vision for some length of time and may make bright lights bothersome. I understand that due to this, driving may be difficult and have made appropriate arrangements. I hereby authorize my doctor and/or his/her assistant to administer dilating eye drops, since dilation may be necessary to diagnose my ocular medical issues. Signature Date

3 MARYLAND VISION INSTITUTE Please review and sign at the bottom. Patient Name: Date of Birth: Acct #: Insurance Claim Filing Guidelines for Exams Maryland Vision Institute may submit claims to either medical insurance or vision insurance. Unless your medical insurance has a special provision stating they will cover one routine vision exam per year, a medical diagnosis must be present in order for them to pay the claim. The vision plans our office accepts are EyeMed, VSP, MetLife VSP, American Benefit and certain Lions Club memberships (with a confirmation letter stating what they will pay). These plans cover yearly routine vision exams and refractions (testing necessary to complete an updated eyeglass/contacts prescription). They will not pay for the treatment of medical conditions. They will still cover routine exams if the patient has a history of, or are screened for, glaucoma, hypertension and/or diabetes. However, they will not cover the exam if the patient is treated for any of those medical conditions or have diagnostic testing on the same day. If we are treating a medical condition but you also have a refraction performed, your medical insurance may not cover the $30.00 charge for the refraction testing. A refraction is considered a routine vision procedure. If you wish for us to submit your claim to one of the vision plans listed above, please provide our receptionist with your vision insurance information including your policy I.D. number. When you are taken to a treatment room, notify the technician that you do not wish to be treated for any medical condition. Patient or Guarantors Signature Date

4 PRIVACY PRACTICES ACKNOWLEDGEMENT I have received the Notice of Privacy Practices and I have been provided an opportunity to review it. Name DOB Signature Date I hereby authorize the release of information: To: (Relationship: Spouse, Relative, Caregiver or Friend) medical information ONLY Initials billing / financial information ONLY Initials both medical and billing / financial information Initials

5 This release will remain in effect until changed in writing. Maryland Vision Institute 301/ PATIENT HISTORY Inventory 220 Champion Drive Suite 100 Hagerstown, MD Fax: Male or Female Visit Date Referred By Referral Phone Date of Birth (circle one) Patient Name Primary Care Physician PCP Phone Address Home Phone City, State Zip Cell Phone Address Medical History Medications None Taken or List Below Name Dosage Frequency Reason for EYE Medications: None Taken or List Below Name Dosage Frequency Reason for Allergies: None Known Latex Eye History Wear Glasses for (circle all that apply)? Nearsightedness Farsightedness Astigmatism Reading

6 Wear Contacts for (circle all that apply)? Nearsightedness Farsightedness Astigmatism Reading Glaucoma Lazy Eye Injury Macular Degeneration Cataract List Others Below Eye Surgery, Event or Disease R eye L eye Date Illnesses Diabetes Heart Disease Asthma High Blood Pressure Emphysema Stroke Cancer Arthritis COPD High Cholesterol CHF Sleep Apnea ( C Pap machine? ) None or List Others Surgery Tonsils Appendectomy Heart Gallbladder None or List Others FAMILY HISTORY Relationship to Patient Relationship to Patient Y N Mother Father Sibling Grandparent Y N Mother Father Sibling Grandparent Blindness Heart Disease Glaucoma High B/P Arthritis Kidney Disease Cancer Lupus Diabetes Stroke Review of Systems Y N If YES, Please Explain General/ Constitutional (fever, weight loss, obesity, etc.) Integumentary / Skin (rash, growths, hair loss, etc.) Ears (hearing loss, drainage, etc.) Neck (swollen glands, thyroid, etc.) Respiratory (congestion, wheezing, COPD, etc.) Cardiovascular (high B/P, racing pulse, etc.) Gastrointestinal (stomach upset, diarrhea, constipation, etc.) Genito-Urinary (painful or frequent urination, impotence, etc.) Musculo-Skeletal (joint pain, stiffness, swelling, cramps, etc.) Neurological (seizures, convulsions, numbness, headache, weakness, etc.) Endocrine (bruising, diabetes, hypothyroid, etc.) Hemato-Immunologic (anemia, high cholesterol, bleeding tendencies, etc.) Psychiatric (anxiety, depression,

7 insomnia, etc.) Do you drink alcohol? If Yes: occasionally 1/day 2-3 day 4+ day Do you smoke? If Yes: occasionally ½ pack day 1 pack day 1+ packs day Current Occupation: Patient Signature:

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