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Patient Information:Last: __________________First: _________________MI__________ Address: ________________________________________________ ________________________________________________ Tel: (___) _ __________ Email: ____________________________ Date of Birth: _______________ Age: _____ Sex: M/F Purpose of visit: ______________________________________ ___________________________________________________ Current Medications: ____________________________ __________________________________ _____ ____________________________________ ____Allergies: ___________________________ _____ Surgical History: _______________________ ___ Social History: Do you use cigarettes/alcohol? Y/N Freq: ______ _ Ocular History: Date of Last Eye Exam: _____________ ___ Have you ever experienced, been diagnosed or treated for any of the following? ??Blurry ? Vision Burning ??Cataracts ??Corneal Abrasions ??Crossed eye/Eye turn ??Double Vision ??Eye Infections ??Eye Injury ??Flash of light ??Floaters/Spots ??Glaucoma ??Grittiness ??Headaches ??Iritis/Uveitis ??Itchiness ??Lazy Eye ??Macular Degeneration ??Occasional dryness ??Retinal Detachment ??Sunlight Sensitivity ??Tearing ??Night vision hard Family Ocular History:Is there a family medical history of the following?Blindness ____________________________y/nCataracts ____________________________y/nCorneal Problems ____________________________y/nDiabetes ____________________________y/nGlaucoma ____________________________y/nHeart Disease _________________________ y/nLazy Eye ____________________________y/nMacular Degeneration ___________________________y/nRetinal Problems ____________________________y/nVisual Needs Assessment: Hours of computer usage: _______________ _____ Hours of outdoor activity: _________________ ___ Hobbies: _____________________________ _____ Eyestrain/neck strain/headaches: __________ ___ Sports: ______________________ ___ Hours before reading fatigue? ______________ ___ Vision Insurance Information: Vision Insurance (Circle): VSP / EyeMed / Davis / Always Care / Spectera /Other: _______________________ Medical Insurance Information Medical Insurance: ___________________________PPO/HMO/IPA Member ID: ____________________ Group ID: _________________ Policy Holder's Name (Last,First): ___________________________ ___ Policy Holder DOB: ___/___ /____ SSN: _____________________ Relationship to Patient: _________________________________ Who can we thank for your referral to our office? Medical History: Have you ever been diagnosed or treated for any of the following health problems? (circle yes, no and f for family history) Allergies _______________________y/n/f Arthritis _______________________y/n/f Blood/Lymph _______________________y/n/f Cancer _______________________y/n/f Cholesterol _______________________y/n/f Diabetes _______________________y/n/f Digestive/Gastric _______________________y/n/f Ears/Nose/Throat _______________________y/n/f Endocrine _______________________y/n/f Fatigue _______________________y/n/f Fevers _______________________y/n/f Heart Disease _______________________y/n/f High Blood Pressure _______________________y/n/f Immune _______________________y/n/f Integumentary (Skin disease) _______________________y/n/f Kidney _______________________y/n/f Muscle Bone _______________________y/n/f Neurological/Headaches _______________________y/n/f Psychological _______________________y/n/f Respiratory _______________________y/n/f Sinus _______________________y/n/f Stroke/Seizures _______________________y/n/f Throat Infections _______________________y/n/f Thyroid _______________________y/n/f Unusual Weight Loss/Gains _______________________y/n/f Understanding Your Vision Benefits???Let’s face it, insurance can be confusing. This is particularly true when an individual has both medical and vision coverage. Understanding your insurance PRIOR to any service can help you avoid confusion and frustration.??VISION INSURANCE is one of the most misunderstood benefits of all health-related coverage. Some insurance companies do a better job of educating their clients than others. At times insurance companies’ “customer service” departments overstate benefits (and minimize or even ignore specific limits and restrictions) that can create an adversarial relationship between the patient and the doctor’s office. We would like to avoid these misconceptions, and we hope that the following will help you better understand how vision coverage works.???Medical vs. Vision??Medical insurance DOES NOT cover vision related issues such as routine exams, glasses, and contact lenses. Many people with medical insurance have a separate rider policy to cover routine eye exams. Most vision plans do not cover ANY medical testing, diagnosis, consultation or treatment. Vision insurance covers ONLY routine eye exams for purchasing glasses or fitting and purchasing contact lenses. Regardless of your vision insurance, most plans do not cover 100% of expenses, and thus you should expect some out-of-pocket costs. There may be co-pays, deductibles or a percentage of costs that you will pay out-of-pocket as required by your insurance policy. As with most doctors, at All Eye Care the patient’s portion must be paid before materials (glasses or contacts lens) can be ordered. And all co-pays are due at the time services are rendered.??MEDICAL concerns (Glaucoma, Dry Eyes, Macular Degeneration, Red-Eyes, Floaters, Allergic Conjunctivitis) take priority and as such will be treated first or concurrently with a vision problem. Sometimes a medical condition has to be treated and corrected before vision can be accurately evaluated. Medical insurance companies usually separate the components of an eye exam, one being the comprehensive exam and the other being the refraction. (The refraction determines the prescription for eyeglasses and contacts.) Typically, VISION insurance policies usually cover both the ROUTINE EXAM and REFRACTION, while MEDICAL policies cover the EXAM only. You are responsible for the cost of the refraction if your insurance is medical only. If the presence of disease is detected that require additional testing, the doctor will provide you information regarding the condition and the testing required.???Although our staff members are very knowledgeable about insurance plans, remember that it is not the doctor’s or staff’s responsibility to know the details of your individual plan. It is to your benefit to be aware of possible deductibles and co-pays that are part of your plan. Your insurance plan may cover routine vision care, but if your deductible has not yet been met, you will still have to pay for the service until your deductible is met. Your insurance is a contract between you, your employer and the insurance company; not with the doctor. We encourage you to speak with your insurance company PRIOR to your appointment about your plan’s specific details. Then, as always, feel free to ask us questions about how they will apply to your upcoming visit. We will do everything we can to help you better understand your policy, but the more knowledge you have about how it works ahead of time, the less frustrating it will be for you at the time of the exam.?What is a refraction? Refraction is a measurement taken by an eye doctor to determine whether a patient has nearsightedness (myopia), farsightedness (hyperopia), or astigmatism. Based on the results of the refraction, the doctor decides whether or not to prescribe glasses. A refraction can be accurately performed on a patient of any age, with or without his or her input. For the majority of patients, refraction is a critical component of an eye examination. Will your insurance pay for a refraction? Even though this is a vital test in the care of your eyes, the refraction is a non-covered benefit with most insurance plans. Unfortunately, they do not differentiate between “medical refractions” and refractions performed for the purpose of providing glasses or contact lenses. We are required to charge for this service regardless of whether your insurance company will cover the service as a benefit of your insurance plan. There is a fee of $40.00 for this test. You will be asked to pay at the time of your visit. This fee will be charged to you approximately one time per year. This is a routine charge at all medical, optometric and surgical ophthalmology practices. _____ I understand that a refraction is a non-covered service and request an updated prescription and evaluation to properly assess my best corrected vision. Notice of Privacy Practices Patient AcknowledgementI have received this practice’s Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practice’s legal duties with respect to my protected health information. The Notice includes: ??A statement that this practice is required by law to maintain the privacy of protected health information. ??A statement that practice is required to abide by the terms of the notice currently in effect.??Types of uses and disclosures that this practice is permitted to make for each of the following purposes: Treatment, payment and health care operations ??A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization. ??A description of uses and disclosures that are prohibited or materially limited by law. ??A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization. ??My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:The right to complain to this practice and to the Secretary of HHS if I believe my privacy rights have been violated and that no retaliatory The right to request restrictions on certain uses and disclosures of my protected health information and that this practice is not required to agree to a requested restriction. The right to receive confidential communications of protected health information. The right to inspect and copy protected health information The right to amend protected health information The right to receive an accounting of disclosures of protected health information The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request. This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice’s current Notice of Privacy Practices on request. Patient: Name: _________________________________________________________________________________ Date of Birth:_______________ Signature: _________________________________________________________________________________ Date: __________________________ Relationship to patient (if signed by a personal representative of patient):__________________________________________________________ I authorize my records to be released to the following individual (s): _______________________________________________________________Payment Policy: I hereby assign all medical benefits, to include all major medical benefits to which I am entitled, including Medicare, private insurance and any other health plans to TRIO EyeCare. A photocopy of this assignment is to be considered as valid as an original. I hereby authorize said assignee to release all information necessary to secure the payment. If my insurance company has not reimbursed TRIO EyeCare within 60 days, I may be billed for any services or products that you have received. I certify that my responses on this form are accurate to the best of my knowledge. I certify that I understand cancellations on eyeglasses are not permitted as all eyeglasses are custom crafted for each patient with their unique prescription.I certify that I understand that there are no refunds or exchanges and that all sales are final unless covered under manufacturer warranty or office warranty programs. Signature:___________________________________________________________________________________________Date:____________________________Retinal Examination: Our Doctor is concerned about retinal diseases such as macular degeneration, glaucoma, retinal detachments, and diabetic retinopathy; all which can lead to partial loss of vision or blindness. Additionally, systemic diseases such as diabetes and high blood pressure can be detected with a retinal examination. Eye exams with retinal evaluations can help you safeguard both your eyesight and general health. The Optomap Digital Retinal Imaging allows us to thoroughly evaluate your internal eye health with dramatically improved precision that includes a depth in the retina not seen with regular dilation. With an annual Optomap, our doctor can track your eye health for concerns, comparison, and treatments. Because Medical and Vision insurances do not pay for routine photos, there is a $40.00 fee for this procedure. (Please advise staff if you have a history of epilepsy.) The Optomap augments a dilated exam by creating a permanent documentation of the interior retina. _____ I elect to have an Optomap Digital Retinal Scan of my retina and understand the scan will provide a permanent baseline comparison for my future visits. I understand that based on the doctor's examination a dilation may still be recommended or necessary. _____ I DECLINE the Optomap Retinal Scan and am choosing to only be dilated today. I understand that my vision will be slightly blurry after dilation and light sensitive for 3-4 hours.I understand I am responsible for any fees associated with medical services which may be non-covered benefits. Print Name: _________________________________Signature _____________________________________Date:________________CONTACT LENS CARE AGREEMENT:Contact lenses are a Class 1 medical device that have the potential for serious complications if not used and fitted properly. For that reason, the standard of care and the requirements of the Louisiana Board of Optometry require an annual examination for renewal of a contact lens prescription. In addition to general eye health assessment, the doctor will assess issues related to contacts such as abnormal blood vessel growth, corneal damage, chronic inflammation, hygiene, discomfort, poor surface compatibility in addition to any vision changes. The estimated fee for these services range depending on the prescription. These fees will cover any contact lens related follow ups for a 30 day period. An additional charge of $50.00 will be assessed after this trial period.By signing, you acknowledge that you understand the policies regarding the fitting of contact lenses and agree to the associated fees. You understand that these fees are an estimate and are subject to changes based on the doctor’s final assessment. You also understand that improper usage of contact lenses as prescribed can lead to vision loss and permanent eye damage and if an infection is present you will need to be treated under your medical insurance prior to being fit with contact lenses. Signature: _________________________________________ Date: ____________________________________ COVID-19 PANDEMIC ESSENTIAL EYE EXAM AND TREATMENT CONSENT FORMPlease read the following statements and initial next to the following statements to indicate your agreement. If you cannot positively affirm to all of these questions, you will be asked to postpone or reschedule your visit to a later date.I do not currently, nor have I had in the last two weeks, a fever, cough, sore throat, loss of smell/taste or other cold symptoms.To the best of my knowledge, I do not have, nor have I been in direct contact with someone who has confirmed diagnosis of COVID-19 or a presumptive positive COVID-19 test result in the last thirty days.Neither I, not anyone living in my immediate household, have traveled outside of the state in the last 30 days.On March 16th, 2020, The Centers for Disease Control and Prevention (CDC) issued the following Public Health Reminder:Healthcare facilities and clinicians should prioritize urgent and emergency visits and procedures now and for the coming several weeks/months. The following actions can preserve staff, personal protective equipment, and patient care supplies: ensure staff and patient safety; and expand available hospital capacity during the COVID-19 pandemic.Delay all elective and ambulatory provider visitsReschedule elective and non-urgent admissionsDelay inpatient and outpatient elective surgical and procedural casesPostpone routine dental and eyecare visitsI have read the above Public Health Reminder and have answered the health questions above honestly and to the best of my knowledge. I understand that TRIO Eyecare, Dr. Amin, and staff are taking precautions to limit any potential exposure I may have to the COVID-19 virus. I also understand that there is no definitive way to eliminate 100 % potential exposure.By signing this form below, I agree that I will not hold TRIO Eyecare, Dr. Amin, or staff personally responsible should I, or someone I come in contact with, become positive or presumptively positive diagnosed with the COVID-19 virus. There are certain inherent risks associated with an eye exam during a pandemic and I assume full responsibility for personal illness that may result and further release and discharge TRIO Eyecare, Dr. Amin, and staff for injury, loss or damage arising out of my visit. I understand that COVID-19 infection can lead to illness, disability, or even death and knowingly take the risk of exposure as I deem my eye exam to be essential to the maintenance of my vision.Print Name: ______________________ Signature:___________________________ Date: ___________ ................
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