Ophthalmologist in Chandler, AZ | Chandler Eye Center
Chandler EYE CenterRobert C. Davidson, M.D.PATIENT INFORMATION:PATIENT’S NAME: Last Name ______________________First Name ____________________ Middle Initial____SEX: Male ___ Female ___ DATE OF BIRTH: ____/____/____ SSN: ___________________ADDRESS ____________________________________________________APT. #_________CITY ______________________________STATE _______ ZIP CODE __________________PHONE NUMBER: PRIMARY___________________SECONDARY _________________E-MAIL ____________________________ LANGUAGE: English ___ Spanish ___ Other ___MARITAL STATUS: Single ___ Married ___ Divorced ___ Separated ___ Widowed ___ETHNICITY: Hispanic or Latino ___ Not Hispanic or Latino ___ Unknown ___ Decline___RACE: White ___ African American___ Native American___ Asian___ Other ___ Decline___PRIMARY CARE DR.________________________________PHONE #_________________PREFERRED PHARMACY __________________________ PHONE # _________________EMERGENCY CONTACT____________________________PHONE #__________________HOW DID YOU HEAR ABOUT US?______________________________________________EMPLOYER__________________________OCCUPATION___________________________Chandler EYE CenterRobert C. Davidson, M.D.RESPONSIBLE PARTY INFORMATION (If NOT the patient):Last Name __________________________ First Name __________________________Middle Initial ______Sex: Male ___ Female ___ Date of birth: ____/____/____ SSN: _____________________________________Address _____________________________________________________________APT./UNIT #_________City ___________________________State_____ Zipcode ___________E-Mail_________________________Phone Number: Primary _____________________________Secondary ______________________________Language: English ___ Spanish ___ Other ___ Relationship to Patient: ________________________________PRIMARY INSURANCE: Name of Insurance Co.:_________________________________________Policy # ______________________Policy Holder’s Name:_________________________________________Group #_______________________Relationship to Patient:________________________________________ Date of Birth: ____/____/____SECONDARY INSURANCE (If Applicable):Name of Insurance Co.:_________________________________________Policy # ______________________Policy Holder’s Name:_________________________________________Group #_______________________Relationship to Patient:________________________________________ Date of Birth: ____/____/____MEDICARE PATIENTS ONLY:(12) Working Aged _____ (13) End Stage Renal Disease _____ (14) Auto No Fault Insurance ______(15) MSP Workers Compensation _____ (16) Federal _____ (41) Black Lung _____ (42) VA _____(43) Disability Insurance _____ (47) Other/Liabilities ___________Chandler EYE CenterRobert C. Davidson, M.D.OFFICE POLICIES AND PROCEDURESThank you for choosing Chandler Eye Center as your vision care provider. We are committed to providing you with the best possible care. The following information will hopefully answer any questions that you may have about our office policies and procedures. REQUIRED AT CHECK IN:Verify personal contact informationPresent current copy of insurance cardPresent current picture IDPayment of any outstanding balancePayment for today’s visit FEES AND PAYMENTSWhile, filing insurance claims is a courtesy that we extend to all of our patients, all charges are your responsibility from the date services are rendered. In order for us to file a claim on your behalf, you must present a CURRENT copy of your insurance card(s) at each visit and communicate any changes in your personal information. Not all services are a covered benefit, so it’s very important that you understand the provisions of your individual policy. You are responsible for the unpaid balance of your visit including deductibles, coinsurance, and non-covered services. CO-PAYMENTSYour insurance company requires us to collect co-payments at the time of service. Waiver of co-payments may constitute fraud under state and federal law. If you do not have your co-payment, your appointment may be rescheduled. MISCELLANEOUS CHARGESNon-sufficient funds checks are subject to a $25 fee. Accounts that are not paid within 90 days from the date of service may be sent to an external collection agency and reported to a national credit bureau. In addition to your outstanding balance, a 33% surcharge may be added to cover cost. In addition, you may be removed from the practice. Please note a fee of $0.25 per page for our staff to provide paper copies of medical records. The fee for completion of DMV paperwork is $25.00 to be paid at time of request. Printed Name:______________________________Signature:_______________________Date:___/___/___Chandler EYE CenterRobert C. Davidson, M.D.Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patients Rights section describing your rights under the law. You have the right to review our notice before signing the acknowledgement. By signing this form, you acknowledge that you had the opportunity to review the Chandler Eye Center Notice of Privacy Practices describing the use and disclosure of protected health information about you for treatment, payment, health care operations, and other uses and disclosures as stated in our Notice. We provide this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION UPON REQUESTI, ______________________________________________, give my permission to disclose protected health information from my health record, including financial information, to the following people:Name (s): _________________________________________________________________________________Patient Signature _______________________________________________________Date _____/_____/_____AUTHORIZATION TO ASSIGN BENEFITS AND STATEMENT OF FINANCIAL RESPONSIBILITYI authorize and request that the payment of Medicare and/or insurance benefits be made directly to Chandler Eye Center. If my health insurance will not allow direct payment to Chandler Eye Center or if Chandler Eye Center chooses not to accept assignment of medical benefits, I agree to immediately forward to Chandler Eye Center any and all health insurance payments I receive. This also applies if coverage is provided by Medicare, a Health Maintenance Organization, a Worker’s Compensation policy, or any other third-party payers. I acknowledge that I am responsible for all charges for services provide by Chandler Eye Center, including any non-covered services or amounts not paid by insurance. Printed Name: ________________________________________________________Signature: ____________________________________________________________Date: _____/_____/_____Relationship to Patient (If other than patient): ____________________________________________________AUTHORIZATION FOR TREATMENTI authorize the health care providers at Chandler Eye Center, to perform diagnostic procedures and treatments as may be necessary for proper medical care for myself or dependent. Printed Name: ________________________________________________________Signature: ____________________________________________________________Date: _____/_____/_____Relationship to Patient (If other than patient): ____________________________________________________Chandler EYE CenterRobert C. Davidson, M.D.TO OUR PATIENTSIMPORTANT INFORMATION ABOUT NON-COVERED/OUT OF POCKET EXPENSESRefraction is a procedure to measure the refractive error of the eyes. We use this measurement to prescribe eyeglass lenses. Medicare considers this a non-covered service, as do most insurance companies. The patient is responsible for paying the fee for refraction.If you would like a prescription for glasses, our fee is $50. We collect this at the time of your visit. We often perform the refraction, but our policy is to the charge the fee only if we provide a prescription for glasses. This service is not required. Please let our technician know if you would like us to perform this service. If you have additional questions, please ask. By signing my name below, I certify that I have read the above information. I understand that if I have any questions, that I can ask the front desk staff or a technician. My signature certifies my understanding of and agreement with the above policies. I understand that I am responsible for all charges not paid by insurance. You may receive a copy of this document upon request. Printed Name: _________________________________________________________________Signature: __________________________________________________Date: ____/____/____Chandler EYE CenterRobert C. Davidson, M.D.Your privacy is important to us. If you are requiring assistance in completing this health questionnaire, please ask our receptionist to direct you to our PATIENT PRIVACY ROOM.HEALTH HISTORY QUESTIONNAIREDate of last eye exam ________________ List any medications you currently take (RX and over the counterNAMEDOSAGEROUTE OF ADMINISTRATION______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Do you have any allergies to any medications or substances including latex? YES NOIf YES, explain ________________________________________________________________List any surgeries you have had and the year(s) they were performed ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Do you currently have any of the following issues related to your EYES? YES NOYES NOBlurred VisionBurningDistorted Vision/HalosDouble VisionDrynessExcess Tearing/WateringEye Pain or SorenessFlashes/Floaters in VisionForeign Body SensationGlare/Light SensitivityGlaucomaInfection of Eye or LidItchingLoss of Side VisionLoss of VisionMucous DischargeRetinal Tear/DetachmentRednessSandy or Gritty FeelingStyes or Chalazion Chandler EYE CenterRobert C. Davidson, M.D.Do you currently have any problems in the following areas? If YES, please provide additional information. YESNOADDITIONAL INFORMATIONCONSTITUTIONAL (Fever, weight loss or gain)CARDIOVASCULAR (High BP, heart trouble, racing pulseEAR, NOSE, MOUTH, THROAT (Allergies, chronic cough, sinus congestion, ear infection)RESPIRATORY (Asthma, shortness of breath, chronic bronchitis)GASTROINTESTINAL (Constipation, diarrhea, ulcers)GENITAL, KIDNEY, BLADDER (Painful or frequent urination, jaundice, impotence, prostate)MUSCULOSKELET?L (Arthritis, joint pain, muscle pain)INTEGUMENTARY (Pimples, warts, growths, eczema)NEUROLOGICAL (Headaches, migraines, seizures)PSYCHIATRIC (Anxiety, depression, insomnia)ENDOCRINE (Diabetes, thyroid/other glands)HEMATOLOGIC/LYMPHATIC (Bleeding, anemia, hepatitis)FAMILY HISTORY (Mother, Father, Grandparent, Sibling)Has any member of your family had these diseases? Circle all that apply.Blindness Cataract Glaucoma Diabetes Stroke Cancer Thyroid Disease ArthritisOther heritable disease: ____________________________________________________________________SOCIAL HISTORYDoes your vision limit any activities of daily living (driving, reading, work, hobbies, etc)? YES NODo you use recreational drugs? YES NO FORMERLY Caffeine? YES NODo you drink alcohol? YES NO If YES, how much? _______________ How often?_________________Do you use tobacco? YES NO FORMERLY If yes, what kind? _______________________________How much? _____________ If FORMERLY, how long?_____________When did you stop?______________Patient/Guardian Signature:_______________________________________Date:____/____/_____ ................
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