Colorado Cataract & Laser, LLC The Center for Eye Care Excellence

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1 Colorado Cataract & Laser, LLC Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma Dear Patient: Thank you for selecting Colorado Cataract & Laser, LLC for your eye care needs. We are committed to providing quality eye care and look forward to meeting you. We have enclosed our new patient forms, with basic information needed for your medical record. Please complete the forms and bring them with you to your first appointment. Bring a current list of all medications and dosages. If you are not sure of the dosages or cannot read the prescription labels, please bring the actual medications with you to your first appointment. If you currently wear glasses, bring them with you. Bring your insurance cards. For our insurance records, we will copy them and keep them in your medical record. Should your insurance carrier require a referral, please bring one with you. Your first visit at Colorado Cataract & Laser, LLC will consist of a complete eye exam. This initial visit usually lasts about 2 hours, but may vary in length depending on the diagnosis made by your doctor. Your eyes may be dilated during this visit. We recommend you bring a pair of sunglasses to protect your eyes from the sun. You may want someone to drive you home. Your appointment is scheduled with: Dr. Jennifer Grin Dr. Teresa Carlson Dr. Andrew Benson On: at: a.m. /p.m. Location: Parker Aurora Our Parker Location is located on 1 st floor of the Sierra Bldg. by the Parker Adventist Hospital. Our Aurora office is located at the Medical Center of Aurora, North side of Hospital. A map is attached with our address and telephone numbers. If you would like more information, please call our office at We look forward to seeing you!

2 Colorado Cataract & Laser, LLC Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma Patient Information: Patient Registration Form Patient Name: Last First Middle Date: Date of Birth: Social Security No.: - - Male Female Marital Status: Single Married Divorced Separated Other Race: American Indian/Alaska Native Asian Black/African American Native Hawaiian/Other Pacific Islander Caucasian Ethnicity: Hispanic/Latino Not Hispanic/Latino Address: City: State: ZIP Home Phone: Cell Phone: Address: Emergency Contact Phone Number Employer: Employer Work Phone: Health Care Providers: Referring Physician Phone: Primary Care Physician Phone: Specialty Care Physician(s) Phone: Preferred Pharmacy and Location: Phone: Insurance and/or Responsible Party: Medical Insurance Primary Carrier: Primary Holder Name: Primary Holder Date of Birth: Primary Holder SSN# ID# Group# Medical Insurance Secondary Carrier: Primary Holder Name: Primary Holder Date of Birth: Primary Holder SSN# ID# Group# (Over, please)

3 Vision Insurance Carrier: Primary Holder Name: Primary Holder Date of Birth: Primary Holder SSN# ID# Group# Financially Responsible Party for Today s Visit: Relationship to patient: Self Spouse Dependent Child Other Worker s Compensation: Is your visit today injury related? Yes No If yes, Date of Injury Worker s Compensation Insurance Carrier: Claim # Employer: Claim Mailing Address: Reason for Today s Visit: Chief complaint (Please check the reason(s) for your visit) blurry spot in vision dizziness glare pain in eye(s) blurry vision double vision glasses re-check red eye(s) bump on eyelid(s) droopy lid(s) glaucoma evaluation swelling burning sensation dry eye(s) headaches watery eye(s) crossed eye(s) eye lashes turning in itchy eye lids wishing to be free of glass or contacts diabetic eye exam flashes itchy eyes routine eye exam discharge floaters injury foreign body sensation distorted vision loss of vision cataracts other: severity none minimal mild significant moderate severe location right Eye left Eye both eyes other timing none intermediately constantly occassionally once This has been going on for Hours Days Weeks Months

4 Colorado Cataract & Laser, LLC * Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma Medical History Form Date: Patient Name: (Last, First, M.I.) Date of Birth: Occupation: Date of Last Eye Exam: Date of Last Physical Exam: ALLERGIES Do you have allergies to any medications? Yes No If yes, please list medications: CURRENT MEDICATIONS (include vitamins and supplements) MEDICAL HISTORY (do you have or have you been treated for): Asthma Hepatitis Type Heart Murmur Arthritis Bronchitis Liver Disease High Cholesterol Back/Neck Problems Emphysema Diabetes Type Ulcers Autoimmune Disease COPD Congestive Heart Failure Thyroid Problems Kidney/Urinary Problems Sleep Apnea High Blood Pressure Anemia Herpes ENT Problems Heart Disease Bleeding Disorders Skin Conditions Hard of Hearing Heart Attack HIV Seasonal Allergies Sinus Problems Stroke GI Problems Anxiety/Depression Headaches Pacemaker GYN Problems Other Psych Disorder Seizures Palpitations Prostate Problems Cancer Other illnesses/injuries: Additional Info: SURGICAL HISTORY (please list all prior surgeries and year they occurred) SOCIAL HISTORY Do you drink alcohol? Yes No Drinks per week Do you smoke? Yes No Packs per day # of Years Previous smoker? Yes No Packs per day # of Years Quit Recreational Drug Use? Yes No Type (year) (Over, please)

5 FAMILY HISTORY (please indicate relationship to patient mother, father, grandparent, etc.) Y N High Blood Pressure Y N Glaucoma Y N Diabetes Y N Macular Degeneration Y N Cancer Y N Cataracts Y N Heart Disease Y N Retinal Detachment Other Y N Lazy Eye/Crossed Eyes REVIEW OF SYSTEMS (do you currently have any of the following problems?) YES NO EXPLAIN Chronic fever, Unexpected weight loss/gain or Fatigue Ears/Nose/Throat (hearing loss, sinus problems, sore throat) Cardiovascular (chest pain, irregular heart beat) Respiratory (asthma, shortness of breath, wheezing, cough) Gastrointestinal (heartburn, abdominal pain, diarrhea) Genitourinary (urinary problems, pain, blood in urine) Dermatological (acne, rashes, dryness, rosacea, psoriasis) Musculoskeletal (muscle aches, joint pain, swollen joints) Neurological (numbness, weakness, headaches, paralysis) Hematologic/Lymphatic (blood disorders, leukemia) Allergic/Immunologic (hay fever, allergies) Endocrine (thyroid problems, diabetes) Psychiatric (depression, anxiety) EYE HISTORY (do you have or have your been treated for) check all that apply Cataracts Iritis/Uveitis Retinal Tear Glaucoma Dry Eye Retinal Detachment Amblyopia (lazy eye) Macular Degeneration Double Vision Strabismus (crossed eye) Floaters Macular Hole Blepharitis (eyelid inflammation) Eye Allergies Eye Injury (explain) EYE MEDICATIONS EYE SURGERIES/LASERS (indicate which eye and year of procedure) CURRENT SYMPTOMS (are you currently having any of the following eye problems? If yes, explain) Do you wear glasses? Yes No Do you wear contacts? Yes No Type Do you have blurred vision? Yes No Do you have difficulty driving due to vision? Yes No Do you have problems with night vision? Yes No Loss of central or peripheral vision? Yes No Glare/Light Sensitivity? Yes No Dryness? Yes No Tearing? Yes No Itching/Allergies? Yes No Mucous Discharge? Yes No Redness? Yes No Foreign body sensation? Yes No Infection Eye or Lid? Yes No Eye Pain/Soreness? Yes No Double Vision? Yes No Floaters/Flashes of Light? Yes No Crossed Eye? Yes No Drooping Eyelid? Yes No Are you interested in learning if you are a candidate for LASIK? Yes No

6 Colorado Cataract & Laser, LLC Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma

7 Colorado Cataract & Laser, LLC Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma Agreement of Responsibility I understand that professional services, diagnostic tests and other medical services rendered to the patient are the financial responsibility of the patient or the patient s guarantor (the responsible party in the case of minors). I understand that I am financially responsible for all charges not covered by my insurance company. Eyeglass Prescription (Refraction): I understand that refraction is a service that is not covered by Medicare or most health insurance carriers. If your doctor provides a refraction with an eyeglass and/or contact prescription, you will be responsible for this charge, which is payable at the time of service. Consent to Treat: I voluntarily consent to such care and treatment as prescribed by the physician as is necessary in his or her judgment. Release of Information Assignment of Benefits: I authorize use of this form on all my insurance submissions and authorize release of information needed to process a claim to any of my insurance companies. I permit a copy of this to be used in place of the original. I authorize the provider to act as my agent in helping me obtain payment from my insurance companies. I understand the provider does not accept responsibility for collecting my insurance claims or for negotiating a settlement in disputed claims. I assign any rights and claims for reimbursement of expenses allowable under my insurance plan and authorize payment directly to the provider for services rendered. I understand I will receive a monthly statement for any balance due by me. I hereby authorize Colorado Cataract & Laser, L.L.C., its agents, employees and affiliates to have access to my complete medical records for the purpose of performing its billing and management functions as they deem necessary. Medicare Authorization (if applicable): I request payment of authorized Medicare benefits be made on my behalf to Colorado Cataract & Laser, LLC for any services furnished to me by that physician or supplier. I authorize the holder of medical information, about me, to release to Medicare and its agents any information needed to determine these benefits or the benefits payable to related services. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes the release of the information to the insurer to the agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance and any uncovered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier. Medigap Authorization (if applicable): The following is to be filled out if you have a Medigap insurance policy for which you wish to assign benefits. A Medigap or Medicare Supplemental policy is a health insurance policy or other health plan, offered by a private company, to those entitled to Medicare benefits. It is designed to pay certain costs that Medicare does not pay. By law, his excludes a policy or plan offered by an employer to employees or former employees, as well as a policy or plan or offered by a labor organization to member or former members. Name of Insurance This agreement is in effect until revoked in writing by the patient, Patient Name: First Middle Last Patient (Guarantor) Signature: Date

8 Colorado Cataract and Laser, L.L.C. Release of Information Patient Name Date of Birth / / I choose not to share my information with anyone. OR I authorize Colorado Cataract and Laser to share information from my records with the following: Share ALL Information Appointment Treatment Billing Health History* Name Relationship Name Relationship Name Relationship *The following information will not be released unless noted here: ALL Substance Abuse HIV Pregnancy Abortion Mental Health Sexually Transmitted Diseases Name Name Name I understand that once this information is released, it is subject to redisclosure by the receiving party. Signature Date Patient must sign, except where there is a Power Of Attorney on file, legal guardianship or the patient is a minor.

9 This lifetime authorization may be revoked at anytime. Colorado Cataract & Laser, LLC Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma Acknowledgement of Receipt of Notice of Privacy Practices I,, have received the Notice of Privacy Practices from Colorado Cataract and Laser, L.L.C. X Date: Colorado Cataract and Laser, L.L.C. Staff Only: In Lieu of patient signature, I,, A staff member of Colorado Cataract and Laser, L.L.C., state that the patient, Has been given our Notice of Privacy Practices.

10 Colorado Cataract & Laser, LLC Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma Summary of Our Notice of Privacy Practices Effective Date: October 3, 2014 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. Please review the full Notice of Privacy Practice (NPP) which is available to you. If you have any questions about this notice, please contact the Administrator at (303) WHO WILL FOLLOW THIS NOTICE: Colorado Cataract and Laser, L.L.C. This notice describes our privacy practices. All these entities, sites and location follow the terms of this notice. In addition, these entities, sites and locations may share health information with each other for treatment, payment, or health care operations purposes described in this notice. OUR PLEDGE REGARDING HEALTH INFORMATION: We understand that health information about you and your healthcare is personal. We are committed to protecting health information about you. We created a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information. We are required by law to: Make sure that health information that identifies you is kept private; Give you this notice of our legal duties and privacy practices with respect to health information about you; and Follow the terms of the notice that is currently in effect. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. By coming for care, you give us the right to use your information for treatment, to get reimbursed for your care, and to operate our organization.

11 There are also various other ways in which we may use or disclose your information: Appointment reminders Health-related services and treatment alternatives To provide information about Organ and Tissue Donation To allow oversight of the quality of the healthcare we provide To allow Workers Compensation Claims As required by Subpoena in Lawsuits and Disputes Various uses as required by law or to avert a serious threat to Health or Safety The full details for all these uses are contained in the full NPP. YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU: You have the following rights regarding health information we maintain about you: Right to Inspect and Copy Right to Amend Right to an Accounting of Disclosures Right to Request Restrictions Right to Request Confidential Communications Right to a Paper Copy of this Notice Information on how to exercise these rights can be seen in the NPP or can be obtained from the Administrator at (303) CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register for treatment or heath care services, we will offer you a copy of the current notice in effect. COMPLAINTS If you believe your privacy rights have been violated you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact the administrator. All complaints must be submitted in writing. You will not be penalized for filing a complaint. OTHER USES OF HEALTH INFORMTION Other uses and disclosures of health information not covered by this notice of the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable

12 to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provide to you. Colorado Cataract & Laser, LLC * Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma Aurora Location 1411 South Potomac Suite 140 Aurora, CO Just southwest of Mississippi and Potomac connected to the Medical Center of Aurora From 225, take the Mississippi exit and head WEST towards the mountains. Stay in the left lane and go left at the first light Potomac Street. We are located on the right side connected to the hospital Medical Center of Aurora. Parker Location 9399 Crown Crest Boulevard Suite 120 Parker, CO Just southeast of Parker Road and HWY 470 connected to the Parker Adventist Hospital in the Sierra Building From Parker Road and E470 head southeast on Parker Road and turn left on Crown Crest Boulevard. Pass the round-about and take the 2 nd entrance into the hospital parking lot. We are in the Sierra Building in suite 120.

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