NP PPWK UPDATED 2019 (2)

?Patient Name Date of Birth Age Social Security Number ______-______-_______ Sex _____________ Marital Status ________________ Address: (Street, Apt #) (City) (State) (Zip) Phone: (H) ______________________ (W) _________________________ (C) ____________________ Do you allow text messaging for appointment reminders: Yes ____ No ____Email Address: ________________________________ @______________________ Ethnicity & Race: ____________________ Preferred Language: ________________________________ Emergency contact: Name & Relation: ________________________Phone: ____________________ Name & phone number of Referring Physician: _____________________________________________ Name & phone number of your Primary Care Doctor: ________________________________________ Chief Complaint (What brings you here today?): __________________________________________________________________________________________________________________________________Insurance Information: PRIMARY MEDICAL INSURANCE: _______________________________________________________________________________________________________________________ (Policy holder/subscriber) (Date of Birth) (S.S. #) (Policy #) SECONDARY MEDICAL INSURANCE: _______________________________________________________________________________________________________________________(Policy holder/subscriber) (Date of Birth) (S.S. #) (Policy #) VISION INSURANCE: _________________________________________________________________________________________________________________________ (Policy holder/subscriber) (Date of Birth) (S.S. #) (Policy #) Medical History: Please attach or bring a copy of current medications to your scheduled appointment. Current Systemic Medications: Eye Medications/drops/ointments: _________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Complete Surgical History: Allergies to Medications: __________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________ Medical/Family History: (Do you or any family members have any of the following?) Heart Disease Me ? Family member ? Cataract Me ? Family member ? Arthritis Me ? Family member ? Glaucoma Me ? Family member ? Hypertension Me ? Family member ? Macular Degeneration Me ? Family member ? Diabetes Me ? Family member ? Retinal Detachment Me ? Family member ? Kidney Stones Me ? Family member ? Fuchs’ Dystrophy Me ? Family member ? Seizures Me ? Family member ? Lazy Eye Me ? Family member ? High Cholesterol Me ? Family member ? Eye Disorders Me ? Family member ? Other (if yes, please explain) Yes ? No ? Preferred Pharmacy: ___________________________________________________________ Pharmacy Address: _____________________________________________________________ Pharmacy Phone: ______________________________________________________________ Social History: Drugs: _____Yes _____No Alcohol: _____Yes _____No Tobacco: _____Yes _____No Have you lived in a foreign country for a substantial period of time? _____Yes _____No Where? Have you ever had a blood transfusion? _____Yes _____No Have you ever been in intimate contact with a person who had a sexually transmitted disease? _____Yes _____No Are you known to be HIV positive? _____Yes _____No How did you hear about us? _________________________________________________________ PATIENT FINANCIAL RESPONSIBILITY Thank you for choosing Mid-Atlantic Cornea Consultants (MACC) as your healthcare provider. We would like to welcome you to our practice. We are committed to provide you with the highest quality healthcare. Patient Financial Responsibilities The patient is ultimately responsible for the payment of his/her treatment and care. We will submit the claim to the insurance companies. However, the patient is required to provide us with the most current and correct information regarding their insurance. Patients are responsible for copays, coinsurance, deductibles, and all other procedures/treatment not covered by their insurance plans. Patients, who require a referral, are responsible for obtaining the referral from their PCP before their visit. Payment is due at time of service. We accept cash, check, Visa and MasterCard. Patients may incur and are responsible for payment of additional charges for the following: Returned check charge--$25 Extensive forms completion--$25 Please be aware that if you are unable to pay our office the amount due at the time of service, you may be asked to reschedule your appointment. Refraction Policy Refraction is sometimes necessary depending on the patient’s diagnosis and/or complaints presented that day. A refraction is also necessary to prove to insurance the need for cataract surgery. Since most medical insurances will no longer accept a refraction charge, our practice policy is as follows. You will pay $40.00 out of pocket only if you are requesting an updated glasses prescription and we dispense this prescription to you. We ask for all patients to sign our practice policy acknowledging our fee if at any point you wish for these services to be completed.If you are using a vision plan to be seen for routine care your exam benefit through vision will cover your refraction fee. Vision plans we participate with include, Davis, Vision Benefits of America, National Vision Administrators, Spectera, EyeMed and March Vision. Please sign the attached refraction policy acknowledging the above. Patient Authorizations I hereby authorize assignment of financial benefits directly to Mid Atlantic Cornea Consultants and any associated healthcare entities for services rendered as allowable under standard third-party contracts. I understand that I am financially responsible for charges not covered by assignment. I authorize Mid Atlantic Cornea Consultants personnel to communication by mail, answering machine message, email and/or text messaging according to the information I have provided in my patient registration information. Acknowledgement of Patient Financial Responsibility and Practice Policies _____________________________________________ ________________ Patient or Authorized Representative Printed Name Date ______________________________________________ Patient or Authorized Representative Signature ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download