OPHTHALMOLOGY ASSOCIATES, INC
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OPHTHALMOLOGY ASSOCIATES, INC.
Frank J. Fischer, Jr., M.D.
Certified, American Board of
Ophthalmology
Fellow, American College of
Surgeons
Gary B. Schemmer, M.D.
Certified, American Board of
Ophthalmology
Jonathan S. Silbiger, M.D.
Certified, American Board of
Ophthalmology
Frank J. Fischer, III, M.D.
Certified, American Board of
Ophthalmology
Alexei Moraczewski, M.D.
Certified, American Board of
Ophthalmology
215 First Street, North #200
Winter Haven, Florida 33881
(863) 294-5457
254 East Stuart Avenue
Lake Wales, Florida 33853
(863) 678-1050
102 Henry Ave.
Plant City, FL 33563
*813) 704-6090
119 Patterson Road
Haines City, Florida 33844
(863) 294-5457
4337 South Florida Avenue
Lakeland, Florida 33813
(863) 709-9700
5528 US Hwy 98 North
Lakeland, FL 33809
(863)816-0131
3600 US Hwy 27 N.
Sebring, FL 33870
(863)385-3211
Fax: (863) 293-0343
(800) 683-1763 (Florida Only)
Welcome to our practice!
This letter will familiarize you with our office procedures and make your first appointment an enjoyable and worthwhile one.
The First Appointment
The first appointment usually takes from 45 to 90 minutes depending on which tests are needed (subsequent visits tend to be much shorter).
We usually dilate the pupils on the first visit, thus it is usually best to bring someone to drive you home.
Please bring a list of your medications, current insurance cards, photo identification, medical history (forms enclosed) and any records from another treating physician, which may help us in your treatment. Bringing the forms with you to your appointment will help us shorten your wait time.
Referrals and Co-pays
IF your insurance (usually an HMO type) requires a referral from your primary care physician – a current written referral or authorization number must be in our office prior to your visit. Obtaining this authorization is the responsibility of the patient. If we have not received your authorization, your appointment will be rescheduled.
Any required co-pay or unmet deductible will be collected at the time of your appointment. We accept cash, checks, Visa, Mastercard, American Express, and Discover. We also participate with Care Credit.
Attention: Legal guardian/parents:
If you have power of attorney over someone please bring a copy for the patient’s records. If someone other than the parent is bringing a child, the enclosed form will need to be filled out.
Thank you for your confidence in us.
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PATIENT HISTORY RECORD
Have you ever been treated for any medical conditions (e.g., diabetes, high blood pressure, heart disease, etc.)?
Yes ____ No ____ If yes, please explain _____________________________________________________
Have you ever had any eye disease (e.g., glaucoma, cataract, etc.)?
Yes ____ No ____ If yes, please explain______________________________________________________
Have you ever had ANY surgery?
Yes ____ No ____ If yes, please explain ______________________________________________________
Do you take any medications?
Yes ____ No ____ If yes, please list them on the accompanying medication sheet.
Do you have any drug allergies?
Yes ____ No ____ If yes, please explain ______________________________________________________
REVIEW OF SYSTEMS
Do you have any of the following problems: Yes No If yes, please explain:
Tuberculosis (active or inactive) ____ ____ ____________________
Immunodeficient disease ____ ____ ____________________
Hepatitis (any form) ____ ____ ____________________
Heart problems (e.g., chest pain, irregular heart beat) ____ ____ ____________________
Respiratory problems (e.g., shortness of breath, wheezing) ____ ____ ____________________
Gastrointestinal problems (e.g., heartburn, abdominal pain) ____ ____ ____________________
Urinary problems (e.g. pain, blood in urine) ____ ____ ____________________
Ear/nose/throat problems (e.g., hearing loss, sinus disease) ____ ____ ____________________
Musculoskeletal problems (e.g., arthritis) ____ ____ ____________________
Chronic fever, unexpected weight loss or gain, fatigue) ____ ____ ___________________
Skin problems (e.g., rash, excessive dryness) ____ ____ ___________________
Neurological problems (e.g., numbness, weakness, headache) ____ ____ ____________________
Psychiatric problems (e.g., depression, anxiety) ____ ____ ______________________
FAMILY AND SOCIAL HISTORY
Do any medical or eye diseases run in your family (e.g., diabetes, high blood pressure, glaucoma, cataract,
coronary artery disease, strabismus, cancer, or macular degeneration )?
Yes ____ No ____ If yes, please explain ________________________________________________
Do you smoke? Yes ____ No ____ __________________ packs per day
Do you drink alcohol? Yes ____ No ____ __________________ drinks per day
FAMILY PHYSICIAN ___________________________
____________________________________
DATE
________________________________ ____________________________________
CHART NUMBER PATIENT NAME
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ACKNOWLEDGMENT: RECEIPT OF NOTICE OF PRIVACY PRACTICES
I have received a copy of Fischer, Schemmer & Silbiger’s Notice of Privacy Practices effective April 2013. I acknowledge that Fischer, Schemmer, Silbiger, & Moraczewski, M.D., P.A. , the physicians, the technicians, and other Fischer, Schemmer, Silbiger, & Moraczewski, M.D., P.A. staff may use and share my confidential health information with others in order to treat me, in order to arrange for payment of my bill and for issues that concern Fischer, Schemmer, Silbiger, & Moraczewski, M.D., P.A. ’s operations and responsibilities.
Do we have your permission to:
Leave a message on your answering machine or voice mail? ο Yes ο No
Leave a message at your place of employment? ο Yes ο No ο N/A
Discuss your medical condition with any family member or
trusted friend? ο Yes ο No
If yes, whom: ___________________________________ Relationship: ___________
Name (please print): __________________________________
Signature: ___________________________________
Date: _____________________________
I am a parent or legal guardian of ______________________ (patient name). I have received a copy of Fischer, Schemmer & Silbiger’s Notice of Privacy Practices effective April 2013.
Name (please print): __________________________________
Relationship to Patient: Parent Legal Guardian
Signature: ___________________________________
Date: _____________________________
If the individual or parent/legal guardian did not sign above, staff must document when and how the Notice was given to the individual, why the acknowledgment could not be obtained, and the efforts that were made to obtain it.
Notice of Privacy Practices effective April 2013 given to individual on _______________ (date)
In Person Mailing Email Other ______________________
Reason individual or parent/legal guardian did not sign this form:
Did not want to
Did not respond after more than one attempt
Other ______________________________________
The following good faith efforts were made to obtain the individual or parent/legal guardian’s signature. Please document with dates, times, individuals spoken to, and outcome, as applicable, the efforts that were made to obtain the signature. More than one attempt must be made.
In person conversation __________________________________________________
Telephone contact _____________________________________________________
Mailing __________________________________________________
Email ____________________________________________________
Other ______________________________________
Staff Name (please print): ________________________________ Title: ______________
Signature: ___________________________________ Date: ______________________
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***BRING THIS FORM WITH YOU ON THE DAY***
OF YOUR APPOINTMENT
PATIENT NAME: _____________________________________________
PHONE NUMBER: ____________________________________________
E-MAIL ADDRESS:____________________________________________
INSURANCE COMPANY:________________________ID #:___________
MEDICATION ALLERGIES:____________________________________
MEDICATION DOSAGE HOW MANY TIMES
(PRESCRIPTION AND A DAY
NON-PRESCRIPTION
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Release of Medical Information
ASSIGNMENT OF BENEFITS: I voluntarily direct any insurance company (or Attorney at Law) to pay Fischer, Schemmer, Silbiger, & Moraczewski, M.D., P.A., directly for charges for professional services rendered to me. THIS IS A DIRECT ASSIGNMENT OF BENEFITS UNDER THIS POLICY. I agree that I am responsible for any balance over and above insurance/attorney payment for these services. I authorize Fischer, Schemmer, Silbiger, & Moraczewski, M.D., P.A., to initiate a complaint to the Insurance Commissioner for any reason on my behalf. I understand and agree that if collection efforts are necessary to obtain payment on this account, I will be responsible for all costs of such collection efforts, including reasonable attorney fees.
CONSENT TO TREAT: I voluntarily authorize Fischer, Schemmer, Silbiger, & Moraczewski, M.D., P.A. to administer examinations and care as deemed necessary for my condition.
Emergency Contact Name: ________________________________________________
Phone: ___________________________
AUTHORIZATION TO RELEASE RECORDS: I voluntarily authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in my case.
______________________________________________
Patient Name Printed
______________________________________________ __________________
Patient Signature Date
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Thank you for choosing our practice. We always strive to provide the best quality of care and customize vision solutions for our patients. This specific information is provided to our patients so that you have the opportunity to be fully informed before coming in for your appointment.
Cataracts are a normal part of the aging process. Cataracts are typically linked to birthdays-----the more birthdays you have, the more likely you are to develop a cataract. Being diagnosed with a cataract may seem frightening, however, cataract surgery is considered to be one of the safest and most successful surgeries in the United States today.
A cataract is a clouding of all or part of the normally clear lens within your eye, which results in blurred or distorted vision. Cataracts are most often found in persons over age 55, but they are also occasionally found in younger people. A cataract can progress until eventually there is a complete loss of vision in your eyes, and neither diet nor laser treatment will make a cataract go away. However, cataract surgery can help restore your vision long before you experience loss of vision significant enough to interfere with your daily activities.
Here at Fischer, Schemmer & Silbiger, we offer the most advanced options to customize your vision after cataract surgery, based on your individual lifestyle needs. We offer the latest advances and new techniques in cataract surgery procedures. We specialize in the most recent innovative technology, including the AcrySof®, ReSTOR®, & AcrySof® Toric lens. The AcrySof® ReSTOR lens has been uniquely designed to improve vision at all distances----up close, far away and everything in-between. The AcrySof® Toric lens is another new option that corrects cataracts and treats preexisting astigmatism in a single step.
We greatly appreciate your choosing us to serve you for your vision needs. We sincerely hope that you will remember us and recommend us to your friends and family.
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