OPHTHALMOLOGY ASSOCIATES, INC



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Advanced Eyecare Associates

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

Adam C. Breunig, M.D.

Certified, American Board of Ophthalmology

215 First Street, North #200

Winter Haven, Florida 33881

(863) 294-5457

1611 State Road 60 E.

Lake Wales, Florida 33853

(863) 294-5457

119 Patterson Road

Haines City, Florida 33844

(863) 294-5457

4337 South Florida Avenue

Lakeland, Florida 33813

(863) 294-5457

5528 US Hwy 98 North

Lakeland, FL 33809

(863) 294-5457

3600 US Hwy 27 N.

Sebring, FL 33870

(863) 294-5457

Fax: (863) 293-0343



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: _____________________________________________

Second Address (Exp. Northern) _____________________________

PHONE NUMBER: ____________________________________________

E-MAIL ADDRESS:____________________________________________

INSURANCE COMPANY:________________________ID #:___________

MEDICATION ALLERGIES:____________________________________

Social Security Number: ______________________________________

|Medication (Prescription and Non-Prescription |Dosage |How Many Times A Day |

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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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Locations:

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