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Island Retina
Pamela A. Weber, M.D., P.C.
1500 William Floyd Parkway Suite 304 283 Commack Road Suite 325
Shirley, NY 11967 Commack, NY 11725
Office (631) 924-4300 Office (631) 486-6672
Fax (631) 924-2525 Fax (631) 924-2525
PLEASE PRINT CLEARLY
Patient Name_______________________________________________________________________
Responsible Party/Parent Name________________________________________________________
Address___________________________________________________________________________
Street City State Zip
Home Phone # (_______) _________-_________ Cell Phone # (_______) ________-________
Email (Please Provide in Order to Access Patient Portal):
__________________________________________________________________________________
Patient SS #________-________-________ Sex: (please circle one) Male or Female
Birth Date: _______/_______/_______ Age:_______ Ethnicity: _________________________
Family Doctor Name_____________________ Address_____________________________________
Telephone # (_______) ________-________ Fax # (______)_______-_______
Pharmacy/Town____________________ Phone # (_____)______-______ Fax# (____)_____-______
Occupation________________________ Employer________________________________________
Business Phone # (_______) ________-________
Marital Status (please circle one) Single, Married, Divorced, Widow, Partner
Spouse or Partner’s Full name: ____________________________DOB:_______/_______/_______
In Case of Emergency____________________________ Relationship_________________________
Phone # (_______) ________-________
Do you wear glasses? Yes_____ No_____ Did you bring them with you? Yes_____ No_____
Are they for distance? Yes_____ No_____ Are they for reading? Yes_____ No_____
Referred to the office by Dr. (Name) ________________________________________________
Internet_____ Other______________________________________________________________
PAMELA WEBER, M.D., P.C.
ISLAND RETINA
PATIENT NAME: _______________________________________________________________________
Are you a Diabetic: □ Yes □ No If Yes: □ Type 1 or □ Type 2 How long? ________________
What is your current HgA1C? _________________
Have you ever been exposed to any of the following: Please answer all questions:
Lyme’s Disease: □ Yes □ No HIV Virus: □ Yes □ No Herpes Virus: □ Yes □ No
Zika Virus: □ Yes □ No Shingles Virus: □ Yes □ No
Ebola Virus: □ Yes □ No Hepatitis Virus: □ Yes □ No
Medical History: Please list any previous medical history below:
_______________________________ __________________________________
_______________________________ __________________________________
_______________________________ __________________________________
_______________________________ __________________________________
_______________________________ __________________________________
Surgical History: Please list any previous surgeries or procedures below:
______________________________ _______________________________
______________________________ _______________________________
______________________________ _______________________________
______________________________ _______________________________
______________________________ _______________________________
______________________________ _______________________________
I acknowledge that above information is true to the best of my knowledge
X _________________________________________ _______/_______/__________
Patient Signature Date
__________________________________________ _______/_______/__________ Technician Signature (FOR OFFICE USE ONLY) Date
PAMELA WEBER, M.D., P.C.
ISLAND RETINA
LIST OF CURRENT MEDICATIONS:
PATIENT NAME:__________________________________________________________________________
DRUG ALLERGIES: PLEASE CIRCLE: NKDA OR LIST DRUG ALLERGIES BELOW:
MEDICATION NAME: REACTION:
_________________________________ _____________________________________
_________________________________ _____________________________________
_________________________________ _____________________________________
_________________________________ _____________________________________
_________________________________ _____________________________________
MEDICATIONS: [List all tablets, patches, drops, ointments, injections, etc. Include prescription, over-the-counter, herbal, vitamin, and diet supplement products]
MEDICATION NAME: DOSAGE: DIRECTIONS:
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________
______________________________ _________ _______________________________ ______________________________ _________ _______________________________
I acknowledge that above information is true to the best of my knowledge
X _________________________________________ _______/_______/__________
Patient Signature Date
All above medications reviewed on Admission
__________________________________________ _______/_______/__________
Technician Signature (FOR OFFICE USE ONLY) Date
PAMELA WEBER, MD., P.C.
ISLAND RETINA
FINANCIAL POLICY
WELCOME TO OUR PRACTICE:
We are dedicated to providing the best possible care and service to you and regard your complete understanding of your financial responsibilities as an essential element of your care and treatment. Thus, in order to reduce confusion and misunderstanding between our patients and the practice, we have adopted the following financial policy.
Unless other arrangements have been made in advance by either yourself or your health coverage carrier, full payment is due at the time of services.
YOUR INSURANCE:
We have made prior arrangements with many insurers and other health plans to accept an assignment of benefits. We will bill those plans with whom we participate, and will only require you to pay the authorized copayment at the time of service. It is the policy of our office to collect the copayment when you arrive for your appointment.
Managed Care and HMO insurance companies have many rules and regulations. Because we participate in over 70 insurance plans, we can no longer be responsible for ensuring your compliance with your insurance company rules. However, to the extent possible, we will still attempt to assist you in your efforts to understand and comply with your insurance company’s requirements.
If you are in a Managed Care Plan or HMO, please make sure you are aware of the following information:
1. Is a referral from your primary physician needed?
2. Does your referral cover more than this visit?
3. When does your referral expire?
4. Does your insurance company cover routine eye exams?
5. What clinical lab is contracted with your insurance company?
In the event your health plan determines a service to be “not covered”, you will be responsible for the complete charge. Refractive testing is reported separately with other visual examination, although Medicare and some private payers do not cover this service. Please contact your insurance company directly for the answer to these and other questions. You are ultimately responsible to know your own insurance policy and their limitations. If you have any questions, please discuss them with our office manager.
PATIENT’S SIGNATURE X____________________________________ DATE________/________/________
PATIENT’S NAME (PRINTED) _______________________________________________________________
PAMELA A. WEBER, M.D., P.C.
ISLAND RETINA
INSURANCE INFORMATION
Primary Company______________________ Address_________________________________
ID#_______________________ Group#_____________ Phone#(_______) ________-________
Subscriber________________________________ Relationship to Subscriber________________
Subscriber’s DOB________-________-________ Subscriber SS#________-________-________
Secondary Company_______________________ Address______________________________
ID#________________________ Group#____________ Phone# (_______) ________-________
Subscriber________________________________ Relationship to Subscriber________________
Subscriber’s DOB________/________/________ Subscriber’s SS#________-_______-________
Tertiary Company_______________________ Address______________________________
ID#________________________ Group#____________ Phone# (_______) ________-________
Subscriber________________________________ Relationship to Subscriber________________
Subscriber’s DOB________/________/________ Subscriber’s SS#________-_______-________
ASSIGNMENT OF BENEFITS
Your signature is necessary for us to process any insurance claims and to ensure payment of services rendered.
I request that payment of authorized Medicare or other insurance carrier benefits be made on my behalf to the doctors of Island Retina for any services furnished me by those physicians. I authorize any holder of medical information about me to release to my insurance carrier or the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services. Furthermore, I understand that annual deductible amounts and all co-insurance amounts are my responsibility. If I have assigned my medical benefits to any other party (H.M.O.), rendering this office ineligible for payment, I understand that I will be responsible for the entire bill of services.
I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES. I HAVE READ THIS INFORMATION AND UNDERSTAND IT.
Patient’s Signature X_____________________________________ Date_____/_____/______
Responsible Party______________________
PAMELA WEBER, M.D., P.C.
ISLAND RETINA
AUTHORIZATION TO DISCUSS PERSONAL INFORMATION
By signing below, I______________________________________________ hereby give permission to Dr. Weber and the staff of Island Retina to discuss with the following individuals information related to the health care services I receive at the above named physician’s office/physician practice. I agree that this information will be limited to appointment scheduling (date and time), procedure scheduling (date, time, and preparation information) prescription re-fill(s), eye test results, consultation reports, and billing inquires. I agree that this does not include the ability for the individuals noted below to authorize the disclosure of my protected health information to a third party or to request on my behalf a copy of my health information. I agree that this authorization will remain active until I revoke it by submitting an updated authorization to the physician practice noted above.
** If a person calls on your behalf to obtain your information and their name is not on this list they will not be provided any information **
Name of Individual _______________________________ Relationship to patient _____________________
Name of Individual _______________________________ Relationship to patient _____________________
Name of Individual _______________________________ Relationship to patient _____________________
Name of Individual _______________________________ Relationship to patient _____________________
Name of Individual _______________________________ Relationship to patient _____________________
Please list any other doctors who are currently treating you with their location:
Allergist: _________________________________________________________________________________
Cardiologist: ______________________________________________________________________________
Endocrinologist: ___________________________________________________________________________
Gastroenterologist: ____________________________________________________________________________
General Ophthalmologist: _____________________________________________________________________
Nephrologist: _________________________________________________________________________________
Neurologist: _________________________________________________________________________________
Oncologist: _______________________________________________________________________________
Primary Doctor: ____________________________________________________________________________
Rheumatologist: ____________________________________________________________________________
Urologist: ___________________________________________________________________________________________________
Other: ______________________________________________________________________________
X______________________________________________ ________/________/________
PATIENT’S SIGNATURE DATE
Island Retina
Pamela A. Weber, M.D., P.C.
AUTHORIZATION FOR USE OF SIGNATURE ON FILE FOR
CLAIM AUTHORIZATION
__________-__________-__________ _____________________________________
Enrollee SS# Enrollee Name
I, _______________________________, authorize Dr. Pamela Weber
Enrollee Name
To mark the section “ENROLLEE’S OR AUTHORIZED PERSON’S SIGNATURE” with the notation “SIGNATURE ON FILE”.
This section authorizes:
1. The release of any medical information necessary to process this claim.
2. Payment of medical benefits to the undersigned physician or supplier of services described below.
This authorization will remain in force until terminated in writing by the enrollee.
X________________________________________ ________/________/________
Enrollee Signature Date
________________________________________ ________/________/________
Witness Signature (FOR OFFICE USE ONLY) Date
1500 William Floyd Parkway Suite 304 283 Commack Road Suite 325
Shirley, NY 11967 Commack, NY 11725
Office (631) 924-4300 Office (631) 486-6672
Fax (631) 924-2525 Fax (631) 486-6674
PATIENT FINANCIAL RESPONSIBILITY POLICY STATEMENT
We are committed to providing you with the highest quality healthcare. We ask that you read and sign this form to acknowledge your understanding of our patient financial policies.
For ANY services provided by Pamela Weber, MD, you may be responsible for services provided. If your insurance company does not cover these services, then these charges may become an out-of-pocket expense for you. PLEASE NOTE: The Suffolk Surgery Center is a separate entity and will bill separately for any procedures done in their facility. Should you have any questions regarding a bill from The Suffolk Surgery Center, you will need to contact their billing department.
PATIENT FINACIAL RESPONSIBILITIES:
• The patient (or patient’s guardian, if minor) is ultimately responsible for the payment for treatment and care.
• We will bill your insurance company for you. However, the patient is required to provide the most correct and updated information regarding insurance.
• Patients are responsible for payment of copays, coinsurance, deductibles, and all other procedures or treatment not covered by their insurance plan.
• Copays are due at the time of service.
• Coinsurance, deductibles, and non-covered items are due 30 days from receipt of billing.
• Patients may incur, and are responsible for payment of additional charges, if applicable.
• If your insurance company requires you to have a referral to see a specialist, it is your responsibility to make sure you have one at the time of your visit, if you do not have one, your appointment will be rescheduled.
These charges may include:
• Charge for returned checks - $30.00
By my signature below, I hereby authorize assignment of financial benefits directly to and any associated healthcare entities for services rendered as allowable under third party contracts. I understand that I am financially responsible for charges not covered by this assignment.
This contract is valid until the termination of your physician/patient relationship with Pamela Weber, MD.
X________________________________________________ _________/_________/___________
PATIENT’S SIGNATURE DATE
_________________________________________________
PATIENT’S NAME [PLEASE PRINT]
_________________________________________________ _________/_________/___________
WITNESS SIGNATURE (FOR OFFICE USE ONLY) DATE
PAMELA WEBER, M.D., P.C.
ISLAND RETINA
RECEIPT OF NOTICE OF PRIVACY PRACTICES
WRITTEN ACKNOWLEDGEMENT FORM
I, _________________________, have received a copy of Island Retina’s Notice of Privacy Practices.
PATIENT’S NAME
X______________________________________________ ________/________/________
PATIENT’S SIGNATURE DATE
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