SMOKY MOUNTAIN EYE CARE

Transcription

1 SMOKY MOUNTAIN EYE CARE Dr. Coy A Brown 1078 North Main Street Waynesville, NC As a new patient to our practice, Dr. Brown and the entire staff would like to welcome you. We greatly appreciate your choosing our office to provide your eye health and vision care. In order for us to provide you with a personalized visit and provide the most beneficial use of your time with us, Dr. Brown has asked you to complete the following tasks and bring these items with you for your appointment. Completed Welcome to the Office Form: This diagnostic information includes personal and family information needed to establish your file, as well as your current eye health and vision status. Your responses will guide our doctors and staff, and remind us to address any significant issues during your visit. Completed Medical and Eye Health History: Since many general health conditions may be associated with visual symptoms and/or eye health problems, this important record (now required by state health boards and virtually any medical and optical insurance plans) will allow us to care for you as a whole person rather than just a pair of eyes. This form includes a complete list of prescription and nonprescription medication, which may be brought in as a separate list for us to photocopy if you prefer. Insurance cards or claim forms: For any optical and/or medical insurance you may be covered by. (Even for routine visits, if a medical eye condition is discovered during your examination we can submit a claim to your health insurance for the medical evaluation portion of your examination.) Eyeglasses: Please bring ALL pairs of eyeglasses you currently use, including prescription or nonprescription reading glasses, sunglasses, etc. We have instruments to compare the optical power of your old lenses with your new exam findings, thus enabling us to determine and explain how your vision has changed over time. We can also evaluate the condition and fit of your current eyewear. Contact Lenses: It is best to wear your current contacts to your appointment if possible. Next best is to bring them along in your case. If you wear planned replacement or disposable lenses, it is very helpful if you bring along your cartons or lens packets that indicate the lens series, power, manufacture, etc. Eye drops, ointments, etc: Please place any eye drops or ointments that you use in a small bag and bring it along with you. Your doctor will review whether these or appropriate or if a better option is available. Dilation Explained: The doctor may need to use drops to dilate your eyes in order to fully evaluate their internal health. This has the effect of temporarily increasing sensitivity to light and causing fuzzy vision at a near (reading) distance. Therefore, if you want new eyewear or feel you may need to select new eyewear, please come 15 to 20 minutes before your appointment time in order to look at our frame selection. Completing the task list for the items that apply to you enables our staff to better serve you our patient in a more efficient manner. If you have any questions or concerns, please call our office at xt 201. We look forward to meeting you soon!!!

2 Smoky Mountain Eye Care is committed to a lifetime of healthy vision, by providing each patient with the highest quality vision care and consequent quality of life. We will seek continuing education to remain at the forefront of our profession and will offer the latest eye care technology, professional services and products. The visual needs and wellness of each patient will always be our first priority. Everything we do shall communicate this. *** PLEASE GIVE ALL INSURANCE CARDS TO RECEPTIONIST *** Patient s Last Name: First: MI: PATIENT INFORMATION Mr. Mrs. Miss Ms. Marital Status: Single Mar Div Sep Wid Preferred Name: Home Phone : Cell Phone: Birth Date: Age: Sex: ( ) ( ) M F Street Address: Social Security #: Preferred Contact #: ( ) City: State: Zip Code: Occupation: Employer: Employer phone: ( ) Who may we thank for referring you to our office? Friend: Dr. Sign Website Newspaper Insurance List Yellow Pages Other: Other immediate family members seen in our office: INSURANCE INFORMATION Primary Insurance: Subscriber s Name: Subscribers SS#: Group #: Policy #: Co-payment: Patient s relationship to subscriber: Self Spouse Child Subscriber's Employer: Secondary Insurance (if applicable): Subscriber s Name: Group #: Policy #: $ Patient s relationship to subscriber: Self Spouse Child Subscriber's Employer: IN CASE OF EMERGENCY Name of local friend or relative for Emergency Contact: Relationship to patient: Home phone: Work phone : ( ) ( ) ***I understand that Smoky Mountain Eye Care (SMEC) strictly follows the HIPAA guidelines and have been notified of their privacy practice. ***Please be advised if you are using insurance coverage for today's visit, this is a contract between you and your insurance company...not SMEC. ***Insurance may not cover Contact Lens Evaluations and/or fittings; in this case, the patient accepts full responsibility for payment in full for these services at time of visit. ***Some visits may have specialist co-pay. I hereby authorize payment of benefits billed to my insurance to SMEC. I hereby accept responsibility for payment for any service provided to me that is not covered by my insurance, or for fees that exceed the payment made by my insurance. If SMEC does not participate with my insurance, I accept responsibility in full for any services rendered or product purchased. I agree to pay all co-payments, co-insurance, and deductibles at the time the service is rendered. Patient/Guarantor/Parent or Guardian(if under 18) Signature Date PLEASE CONTINUE TO THE REVERSE SIDE PG 1 of 4

3 HIPAA ACKNOWLEDGMENTS ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE I acknowledge that I was given access to, offered, and/or received a copy of, Dr. Coy A. Brown, O.D. s Notice of Privacy Practices. Patient name Signature Date APPOINTMENT REMINDERS We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home. Signature Date RELEASE OF MEDICAL INFORMATION TO FAMILY AND/OR FRIENDS In keep with the Notice of Privacy Act, HIPAA regulations, we are unable to discuss your health care, personal information, or disclose information necessary for your continuum of care with any individual not listed in the Notice of Privacy Act. If you wish for Smoky Mountain Eye Care to be able to discuss or disclose information with certain individuals (not being insurance agencies), please list below the people whom you authorize Smoky Mountain Eye Care to share medical information with. (For example, daughter, mother, sister, friend, etc.) Name Relationship Phone# Patient Signature Date PG 2 of 4

4 SMOKY MOUNTAIN EYE CARE Dr. Coy A Brown 1078 North Main Street Waynesville, NC VISUAL FIELDS TESTING AND DIGITAL RETINAL IMAGING Your health is your most precious asset. Early detection is crucial in the diagnosis and treatment of eye diseases. Dr. Brown is proud to offer the latest technologies in Preventative Eye Care, allowing us to properly diagnose and treat disease conditions as early as possible. In addition to the Basic Vision Exam you have scheduled, we very highly recommend these additional tests: COMPUTERIZED VISUAL FIELDS: This sophisticated computerized instrument allows Dr. Brown to test the optic nerve function and retina. Visual Fields can detect tumors, aneurisms, nerve degenerations, strokes and traumatic brain injures inside the brain that cannot be seen in any other way possible with the exception of MRI or CAT scan technology. It also tests for glaucoma, diabetic retinopathy, macular degeneration and cataracts. DIGITAL RETINAL IMAGING: Through ocular photography Dr. Brown can produce exceptionally clear, detailed images of the tissues of your eye. This will allow Dr. Brown to evaluate the retina and eye tissues in detail for a range of diseases such as glaucoma, macular degeneration and other retinal defects. Patients with diabetes, high blood pressure, cholesterol problems, macular degeneration, glaucoma and other known retinal diseases are strongly encouraged to receive Digital Retinal Imaging. These images can be ed to your personal address and/or sent to your personal physician to have in your health records to compare for diseases that affect your eyes or monitor ocular side effects of medications that treat cholesterol, arthritis and other diseases. Dr. Brown wholeheartedly recommends these examinations, especially if you have a history of diabetes, headaches, migraines, flashes or floaters, cancer, or recent changes in vision or a family member who has or had glaucoma, macular degeneration, cancer, or diabetes. The fee for these exams is $20 for the Visual Fields test, and $30 for the Digital Imaging. You can combine both for a total of $40, for a savings of $10 off. These test are NOT covered by your Vision Insurance. By consenting to these tests you accept the responsibility of paying for this exam. INITIAL NEXT TO APPROPRIATE STATEMENT: YES, I would like to ONLY receive the Visual Fields Screening in addition to my Eye Exam - $20 YES, I would like to ONLY receive the Digital Retinal Photo in addition to my Eye Exam - $30 YES, I would like to receive BOTH tests in addition to my Eye Exam - $40 NO, I would NOT like to receive either test at this time PG 3 of 4

5 Patient Medical History Name of Family Physician/Practice: Preferred Pharmacy: Current Medications and Dosage (including Rx and Over the Counter): Medication Allergies and Reaction: Patient Height: Weight: Have you ever been diagnosed or treated for the following health problems? Environmental Allergies Rheumatoid Osteoarthritis / Arthritis Lupus Fibromyalgia Muscular Dystrophy Ankylosing Spondylitis Heart Disease Hypertension Stroke Cholesterol Crohn's/Colitis Ulcer Digestive Multiple Sclerosis Epilepsy Alzheimers Parkinsons Cerebrovascular Unusual weight loss/gain STD, Viral herpetic, chlamydia Trauma Depression/Panic Disorder Ear, Nose, Mouth or Throat Infection Tinitis Anemia Large volume blood loss Leukemia Asthma/Bronchitis/Emphysema Diabetes Insulin dependent Non-Insulin dependent Thyroid Dysfunction Hormonal Dysfunction Eczema/Rosacea/Psoriasis Have you ever been diagnosed or treated for any of the following? Cataracts Eye Injury Glaucoma Eye Infections Macular Degeneration Iritis/Uveitis Retinal Detachment Lazy Eye Blurry Vision Double Vision Flashes of Light Floaters/Spots Burning Corneal Abrasions Headaches Light Sensitivity Is there a family medical history of any of the following? Blindness Diabetes Cataracts Glaucoma Corneal Problems Heart Disease Lazy Eye Retinal Problems Macular Degeneration Do You... work on a computer? spend time outdoors? have prescription sunwear? wear bifocals? wear contact lenses? have children? have family members in need of eye care? have trouble seeing at night? have trouble seeing to drive in the rain? have uncomfortable glasses? currently use cigarettes or tobacco products? Please list any current visual concerns below PLEASE CONTINUE TO THE REVERSE SIDE PG 4 OF 4