Broome Eye Care & Optical - Home



-5524506987540Who may we thank for referring you to our office? □ Doctor Referral□ Friend / Family□ Internet Website□ Google□ Insurance List□ Advertisement□ Yellow Pages□ Yelp□ Walk-In□ Newspaper□ Direct Mailer□ Customer□ Employee□ Recall Letter□ Radio□ Non-Referral00Who may we thank for referring you to our office? □ Doctor Referral□ Friend / Family□ Internet Website□ Google□ Insurance List□ Advertisement□ Yellow Pages□ Yelp□ Walk-In□ Newspaper□ Direct Mailer□ Customer□ Employee□ Recall Letter□ Radio□ Non-Referral30003754768215Vision Insurance InformationPrimary Vision Insurance: ________________________Member ID#: __________________________________Group #: ______________________________________Subscriber Name: ______________________________DOB: _________________________________________Relationship: __________________________________00Vision Insurance InformationPrimary Vision Insurance: ________________________Member ID#: __________________________________Group #: ______________________________________Subscriber Name: ______________________________DOB: _________________________________________Relationship: __________________________________-5524504768215Medical Insurance InformationPrimary Medical Insurance: _____________________Member ID#: ________________________________Group #: ____________________________________Subscriber Name: _____________________________DOB: _______________________________________Relationship: _________________________________00Medical Insurance InformationPrimary Medical Insurance: _____________________Member ID#: ________________________________Group #: ____________________________________Subscriber Name: _____________________________DOB: _______________________________________Relationship: _________________________________-552450339090Patient Information:Patient Name: _________________________________ DOB: _______________ Social Security #: _______________Address: _______________________________________ City: _________________ State: _______ Zip: ___________Phone #: _(____ )__________________ Cell #:_(____ )__________________ Work #: _(____ )__________________Email: _________________________________________ Sex: □ Male □ Female Race: ___________________________ Ethnicity: ______________________ Preferred Language: _______________Employer / School: ___________________________ Occupation / Grade: ____________________________________ □ Married □ Divorced □ Single □ WidowedSpouse Name: _________________________________ Phone #: _(____ )__________________ Address: _______________________________________ City: _________________ State: _______ Zip: ___________Emergency Contact Information: Name: _______________________________ Phone #: _(____ )________________ Relationship: _________________Preferred Pharmacy: _______________________ Location: ___________________ Phone #: _(___)_______________00Patient Information:Patient Name: _________________________________ DOB: _______________ Social Security #: _______________Address: _______________________________________ City: _________________ State: _______ Zip: ___________Phone #: _(____ )__________________ Cell #:_(____ )__________________ Work #: _(____ )__________________Email: _________________________________________ Sex: □ Male □ Female Race: ___________________________ Ethnicity: ______________________ Preferred Language: _______________Employer / School: ___________________________ Occupation / Grade: ____________________________________ □ Married □ Divorced □ Single □ WidowedSpouse Name: _________________________________ Phone #: _(____ )__________________ Address: _______________________________________ City: _________________ State: _______ Zip: ___________Emergency Contact Information: Name: _______________________________ Phone #: _(____ )________________ Relationship: _________________Preferred Pharmacy: _______________________ Location: ___________________ Phone #: _(___)_______________PATIENT INTAKE FORMPATIENT HISTORY-4953005391150Medications Do you have any drug allergies? □ YES □ NO Drug Name: ____________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Please list any OTC (over the counter) supplements or vitamins? ___________________________________________________________________________________________________________________________________________00Medications Do you have any drug allergies? □ YES □ NO Drug Name: ____________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Name: _______________________________ Mg /Dose: _________________ Route: ___________________Please list any OTC (over the counter) supplements or vitamins? ___________________________________________________________________________________________________________________________________________-4953003764280Past Surgical HistoryDates of Surgery: ________________________________________________□ None □ Appendix □ Gallbladder □ Hysterectomy □ Tubal Ligation□ Tonsillectomy□ Breast ______________________________________□ Colon __________________________________________□ Heart _______________________________________□ Kidney _________________________________________□ Joint Replacement _____________________________□ Other __________________________________________00Past Surgical HistoryDates of Surgery: ________________________________________________□ None □ Appendix □ Gallbladder □ Hysterectomy □ Tubal Ligation□ Tonsillectomy□ Breast ______________________________________□ Colon __________________________________________□ Heart _______________________________________□ Kidney _________________________________________□ Joint Replacement _____________________________□ Other __________________________________________-4953002430780Social HistoryDo you drink alcohol? _______ How often? __________ How much? _________ What kind? Beer ____ Liquor ____ Wine______Do you smoke? _________ How often? _________ How much do you smoke? _____ per day For how long? ______________Do you use recreational drugs? ________ How often? ______ What kind? ___________________________________________00Social HistoryDo you drink alcohol? _______ How often? __________ How much? _________ What kind? Beer ____ Liquor ____ Wine______Do you smoke? _________ How often? _________ How much do you smoke? _____ per day For how long? ______________Do you use recreational drugs? ________ How often? ______ What kind? ___________________________________________-495300373380Patient Medical History: □ None □ Allergies□ Anxiety□ Arthritis□ Asthma□ Atrial Fibrillation□ BPH□ Breast Cancer □ Colon Cancer□ COPD □ Coronary Artery Disease □ Depression □ Diabetes □ End Stage Renal Disease □ GERD□ Hearing Loss□ Hepatitis □ Hypertension □ HIV/AIDS □ High Cholesterol □ Hyperthyroidism □ Leukemia □ Lung Cancer □ Lymphoma □ Prostate Cancer □ Radiation Treatment □ Seizures □ Heart Disease□ Stroke□ Peripheral Vascular Disease □ Other ____________________________________00Patient Medical History: □ None □ Allergies□ Anxiety□ Arthritis□ Asthma□ Atrial Fibrillation□ BPH□ Breast Cancer □ Colon Cancer□ COPD □ Coronary Artery Disease □ Depression □ Diabetes □ End Stage Renal Disease □ GERD□ Hearing Loss□ Hepatitis □ Hypertension □ HIV/AIDS □ High Cholesterol □ Hyperthyroidism □ Leukemia □ Lung Cancer □ Lymphoma □ Prostate Cancer □ Radiation Treatment □ Seizures □ Heart Disease□ Stroke□ Peripheral Vascular Disease □ Other ____________________________________Patient Name: ___________________________ DOB: _________________ Today’s Date: __________________PATIENT HISTORY CONTINUED-5156203973830Ocular Surgeries - Left or Right Eye□ None □ Blepharoplasty□ Cataract Surgery□ Corneal Transplant□ DSAEK □ LASIK□ Intravitreal Injections □ LPI□ LTP □ PRK□ Dry Eyes□ Ptosis Repair □ Narrow Angles □ Punctal Plugs□ Strabismus Surgery□ Retina Laser □ Trabeculectomy□ Tube Shunt□ Yag Capsulotomy □ Foreign Body Removal □ Other ____________________________________00Ocular Surgeries - Left or Right Eye□ None □ Blepharoplasty□ Cataract Surgery□ Corneal Transplant□ DSAEK □ LASIK□ Intravitreal Injections □ LPI□ LTP □ PRK□ Dry Eyes□ Ptosis Repair □ Narrow Angles □ Punctal Plugs□ Strabismus Surgery□ Retina Laser □ Trabeculectomy□ Tube Shunt□ Yag Capsulotomy □ Foreign Body Removal □ Other ____________________________________-5251451945005Ocular History – Left or Right Eye□ None □ Allergic Conjunctivitis□ Blepharitis□ Cataracts□ Contact Lenses □ Corneal Dystrophy□ Diabetic Retinopathy □ Dry Eyes□ Glasses□ Glaucoma □ Macular Degeneration □ Macular ERM □ Narrow Angles □ Ocular Hypertension□ Ophthalmic Migraine□ Pseudoexfoliation□ Retinal Tear □ Strabismus □ PDV □ Vitreous Floaters□ Retinal Detachment□ Corneal Abrasions□ Crossed Eyes □ Double Vision□ Eye Injury□ Grittiness□ Lazy Eye□ Flashes of Light□ Itchiness □ Headaches□ Eye Strain□ Blurry Vision□ Iritis □ Other _______________________00Ocular History – Left or Right Eye□ None □ Allergic Conjunctivitis□ Blepharitis□ Cataracts□ Contact Lenses □ Corneal Dystrophy□ Diabetic Retinopathy □ Dry Eyes□ Glasses□ Glaucoma □ Macular Degeneration □ Macular ERM □ Narrow Angles □ Ocular Hypertension□ Ophthalmic Migraine□ Pseudoexfoliation□ Retinal Tear □ Strabismus □ PDV □ Vitreous Floaters□ Retinal Detachment□ Corneal Abrasions□ Crossed Eyes □ Double Vision□ Eye Injury□ Grittiness□ Lazy Eye□ Flashes of Light□ Itchiness □ Headaches□ Eye Strain□ Blurry Vision□ Iritis □ Other _______________________-5238755697855Family Medical and Ocular History – Circle OneMedical: Please indicate which family member Mother Father Siblings Children Maternal Grand mother / father Paternal Grand mother / father□ Diabetes □ Hypertension□ High Cholesterol□ Heart Disease□ Peripheral Vascular DiseaseOcular: Please indicate which family member Mother Father Siblings Children Maternal Grand mother / father Paternal Grand mother / father□ Glaucoma □ Macular Degeneration□ Retinal Detachment□ Diabetic Retinopathy□ Lazy Eye □ Cataracts00Family Medical and Ocular History – Circle OneMedical: Please indicate which family member Mother Father Siblings Children Maternal Grand mother / father Paternal Grand mother / father□ Diabetes □ Hypertension□ High Cholesterol□ Heart Disease□ Peripheral Vascular DiseaseOcular: Please indicate which family member Mother Father Siblings Children Maternal Grand mother / father Paternal Grand mother / father□ Glaucoma □ Macular Degeneration□ Retinal Detachment□ Diabetic Retinopathy□ Lazy Eye □ Cataracts-522605302260Eye History – Circle OneDo you wear contact lenses or glasses? What kind of contacts? : _________________ Have you ever tried contact lenses: □ YES □ NOHow satisfied are you with your current glasses and or contacts? __________________________________________Do you use a computer, tablet or smart phone more than 1 hour a day? ____________________________________00Eye History – Circle OneDo you wear contact lenses or glasses? What kind of contacts? : _________________ Have you ever tried contact lenses: □ YES □ NOHow satisfied are you with your current glasses and or contacts? __________________________________________Do you use a computer, tablet or smart phone more than 1 hour a day? ____________________________________Patient Name: ______________________ DOB: ____________________ Today’s Date: __________________HIPAA CONSENTAuthorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act ---- 45 CFR Parts 160 and 164)1. I authorize the release of my PHI described in paragraphs 3 a and 3 b of this Authorization, I authorize disclosure of information regarding my billing, condition, treatment and prognosis to the following individual(s): Name _______________________________________ Relationship ______________________ Name _______________________________________ Relationship ______________________ Name _______________________________________ Relationship ______________________ 2. This medical information may be used by the persons I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct. 3. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 4. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. 5. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Patient / Legal Guardian Signature____________________________ Date: _________________Print Name: ____________________________ Relationship to Patient: ___________________GENERAL CONSENT FOR CARE AND TREATMENT TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).This consent provides us with your permission to perform reasonable and necessary medical, visual, optical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.I voluntarily request Frank A. Broome OD and/or Kimberly Broome, OD and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical, visual, optical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.__________________________________________________________________Signature of Patient or Personal Representative Date__________________________________________________________________Printed Name of Patient or Personal Representative Relationship to PatientFINANCIAL RESPONSIBILITY & INSURANCE SIGNATURE ON FILEINDIVIDUAL’S FINANCIAL RESPONSIBILITY I understand that I am financially responsible for my health insurance deductible, coinsurance or non-covered service. Co-payments are due at time of service. If my plan requires a referral, I must obtain it prior to my visit. In the event that my health plan determines a service to be “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided. If I am uninsured, I agree to pay for the medical services rendered to me at time of serviceINSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS I hereby authorize and direct payment of my medical benefits to Broome Eye Care & Optical on my behalf for any services furnished to me by the providers.AUTHORIZATION TO RELEASE RECORDS I hereby authorize Broome Eye Care & Optical to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to any other medical provider.MEDICARE / MEDICAID REQUEST FOR PAYMENT I request payment of authorized Medicare / Medicaid benefits to me or on my behalf for any services furnished me by or in Broome Eye Care & Optical. I authorize any holder of medical or other information about me to release to Medicare / Medicaid and its agents any information needed to determine these benefits or benefits for related services.By my signature below, I hereby authorize assignment of financial benefits directly to Broome Eye Care & Optical for services rendered as allowable under standard third party contracts. I understand that I am financially responsible for charges not covered or denied by this assignment. I will also be responsible for any charges your insurance does not pay within 45 days of the date the claim was submitted, you the patient will be billed for the balance or entire cost of services rendered. I have read the above Financial Agreement policies of Broome Eye Care & Optical, and agree to pay any charges my insurance company does not pay. I understand that some services may not be covered, as dictated by my insurance company. If my insurance company denies the claim as a non-covered service, I understand that I will be responsible for the balance. If my account becomes delinquent, I agree to pay all collection costs, including attorney fees. Patient / Legal Guardian Signature: ____________________________ Date: _________________Print Name: ____________________________ Relationship to Patient: ___________________ ................
................

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

Google Online Preview   Download