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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:

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Surgical History: Please list any previous surgeries or procedures below:

______________________________ _______________________________

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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:

______________________________ _________ _______________________________

______________________________ _________ _______________________________

______________________________ _________ _______________________________

______________________________ _________ _______________________________

______________________________ _________ _______________________________

______________________________ _________ _______________________________

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______________________________ _________ _______________________________ ______________________________ _________ _______________________________

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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