EyeCare Partners, P.C.
Confidential Patient Information and Reference Sheet
Today’s Date______Please Circle One: Mr. Mrs. Ms. Miss Dr.
First Name______Middle Initial______Last Name______Sr. Jr. III IV
Preferred Name ______Sex (circle) F M Date of Birth______S.S.N.______
Address______Apt #_____ City______State ___ Zip______
Home Phone ______Work Phone ______Cell Phone ______
E-Mail Address______Employer/Occupation______
Race(Circle) : White African American Asian Hispanic/Latino Other______
Preferred Language: English Spanish or ______
Do you have Medical Insurance?Yes NoDo you have Medicare? Yes No
Do you have Vision Insurance?Yes No
If Patient Needs Assistance, isunder 18, or is a Dependant, Please List Responsible Party or Contact:
First Name______Middle Initial___ Last Name______Date of Birth______
Relationship to Patient: Mother Father Grandparent Spouse Child Other______
Contact Phone Number:______
Signature______
INSURANCE AUTHORIZATION
I give permission to the doctors and employees at EyeCare Partners, P.C. to release to any health care administration, any medical information about me needed for this insurance claim. I permit a copy of this authorization to be used in place of the original. I request payment of medical insurance benefits be paid to myself or the party who accepts assignment. I understand that my insurance MAY cover all of my fees, but ultimately it is my responsibility to know my insurance benefits and coverage; and to cover all costs for services. I understand any insurance information provided to me by employees of EyeCare Partners, P.C. is not a certification of benefits or a guarantee of payment. Benefits can only be determined by my insurance company at the time a claim is submitted, thus if my insurance carrier determines that the services received are not a covered benefit I am responsible for full payment of all accrued fees.
Signature: ______Date: ______
PRIVACY POLICY NOTICE
I authorize EyeCare Partners to use my information in accordance with the Notice of Privacy Practice (HIPPA). A complete copy of EyeCare Partners’ Privacy Practices is available at the front desk upon request. Authorizations expire three years from date signed.
Signature: ______Date:______
EyeCare Partners, P.C. ExamPolicy
The original eye exam and/or contact lens exam fee(s) today includes up to 90 days of follow up care with the original doctor when related to original services. For different services, visits after 90 days, or services with different doctors additional charges will apply.
Allergic/Immunologic Negative
Drug allergy:______
Environmental allergy
Rheumatoid arthritis
Lupus
Other:______
Eyes Negative
Glaucoma
Cataract
Macular Degeneration
Surgery Type______
Inflammatory disorders
Blurred Vision
Blurred Vision (with glasses)
Double Vision
Other:______
Musculoskeletal Negative
Fibromyalgia
Muscular Dystrophy
Osteoarthritis
AnkylosingSpondylitis
Other:______
Cardiovascular Negative
Heart disease
Hypertension
Stroke
Vascular disease
Other:______
Gastrointestinal Negative
Crohn’s
Colitis
Ulcer
Digestive
Other:______
Neurological Negative
Multiple Sclerosis
Epilepsy
Alzheimers
Parkinsons
Cerebrovascular
Other:______
Constitutional Negative
Developmental disability
Weight loss
Fever
Fatigue
Trauma
Other:______
Genitourinary Negative
STD –Viral, Herpetic, Chlamydia
Other:______
Psychiatric Negative
Depression
Panic Disorder
Schizophrenia
Other:______
Ears, Nose, & Throat Negative
Upper Resp. Tract Infection
Ringing – Tinitis
Ear Ache
Runny Nose
Sore Throat
Other:______
Hematologic/Lymphatic Neg.
Anemia
Large Volume Blood Loss
Leukemia
Other:______
Endocrine Negative
Non-insulin dependent diabetes
Insulin dependent diabetes
Thyroid dysfunction
Hormonal dysfunction
Other:______
Integumentary Negative
Eczema
Rosacea
Psoriasis
Other:______
Respiratory Negative
Asthma
Bronchitis
Emphysema
Other:______
Do You Smoke? Yes No
If yes, Amount______
Are you a former smoker?
Yes No
Are You Pregnant?
Yes No Nursing
Do You Wear Glasses?
Yes No
Do You Wear Contacts?
Yes No
If Yes, what Brand?______
______
If No, are you interested in contacts today? Yes No
When was your last eye exam? ____________
Height______Weight______
Health Care Physician ______
Pharmacy:______
Medications: ______
______
Family History
Disease Relation
Glaucoma______
Cataracts______
Age Related Macular Degeneration______
Hypertension______
Diabetes______