DUPAGE OPHTHALMOLOGY

Balaji Gupta MD ● Sheridan Lam MD ● Natalka Manastersky OD

(Please Print)
Today’s date / Acct / Scanned By

PATIENT INFORMATION

Patient’s Name / Social Security #
Address / Marital status
City / State / Zip / □ Single □ Mar □ Div □ Sep □Wid □ Partnership □ Minor
DOB / Age / Sex / Ethnicity(Mark only one)
Primary Phone# / Secondary Phone# / □ Non-Hispanic / Non-Latino □ Hispanic / Latino □ Decline
Email / Preferred Language(Mark only one)
Patient employer/school /  English  Spanish  Hindi Mandarin Urdu Other
Employer phone / Race(Mark only one) □ White □ Black or African American □ Asian
Employer/School address / □ Native Hawaiian or Pacific Islander □ American Indian or Alaska Native
Occupation / □ Other:______□ Decline
Person responsible for account / Referred by
Phone # / □ Family or Friend □ Insurance □ Hospital □ Internet search  Website
Birthdate / Social Security # / □ Primary Care Physician □ Other Physician □ Other ______
Address (if different from patient’s) / Primary Care Physician
City / State / Zip / Primary Care Physician Phone
Emergency contact / Pharmacy Name Phone#
Relationship / Phone / Pharmacy Address

INSURANCE INFORMATION

Primary Insurance Company / Insurance phone
Policy holder / Birthdate / Relationship
ID # / Group # / Copay
Secondary Insurance Company / Insurance phone
Policy holder / Birthdate / Relationship
ID # / Group # / Copay

ASSIGNMENT AND RELEASE

I certify that I, and/or my dependent, have insurance coverage and assign directly to DuPage Ophthalmology, SC; Balaji Gupta, MD; NatalkaManastersky, OD; Sheridan Lam, MD, all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I authorize the use of my health care information and such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining services and determining insurance benefits or the benefit payable for related services. The consent will end upon termination of coverage with above-named Insurance Company(ies) or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative / Date
Please print name of Patient, Parent, Guardian or Personal Representative / Relationship to Patient

REVISED 8/27/13

Consent to Health Care Services

I authorize the DuPage Ophthalmology providers to perform any and all forms of diagnostic tests, treatments, medication and therapy. I consent to the doctors employing assistance as he or she deems fit. I authorize the office to contact my emergency contact in case it is necessary.

I consent to the use or disclosure of my medical information by DuPage Ophthalmology for the purpose of diagnosing or providing treatment to me, obtaining payment for my treatment or to conduct healthcare operations of the practice. I understand that treatment by the practice may be denied if I do not sign this consent.

I understand and have been provided with DuPage Ophthalmology Notice of Privacy Practices. I understand that I have the right to review the notice prior to signing this consent. DuPage Ophthalmology has the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail or asking for one when I am in the office.

______

Signature of Patient or Authorized Representative Date

I understand that part or all of the services that I receive during my visit may not be covered by my insurance and I acknowledge thatI am responsible for the cost of any such services. I understand that my insurance may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants within 45 days of submission to my insurance company. I am also responsible for all interest, collection, attorney and court fees that will be added to my balance if I fail to pay for these services within the 45 day period.

An example of a non-covered service is refraction. The cost of glasses refraction is $35 and a complex refraction is $50. Vision care services (routine eye exam, contact lens exam) will not be billed to your health insurance.

______
Signature of Patient or Authorized Representative Date

I understand that DuPage Ophthalmologyproviders are NOT in network with my insurance company.

______

Patient or Authorized Representative Date

I understand thatDuPage Ophthalmology does NOT accept new Medicaid patients at this time. My visit will not be billed to Medicaid.

______Signature of Patient or Authorized Representative Date

REVISED 8/27/13

Patient Name: ______

What brings you to the office? ______

Symptoms / Hx of Eye Surgery / Current Eye Problems / Family Hx of Eye Problems / Social History
 / Double vision /  / Eye muscle surgery /  / Diabetic eye problems /  / Allergy/Asthma /  / drink alcohol
 / Flashes or floaters /  / Glaucoma surgery /  / Dry eyes /  / Bleeding disorder /  / smoke
 / Dryness/Irritation /  / Cataract surgery /  / Cataract /  / Blindness /  / use illegal drugs
 / Infection /  / Injections into eye /  / Glaucoma /  / Genetic disease /  / Hx of blood transfusions
 / Itching /  / Laser surgery /  / Macular degeneration /  / Glaucoma
 / Lid bump(s) /  / LASIK/Refractive /  / Retinal problems /  / Macular degeneration
 / Pain /  / Retina surgery /  / Strabismus/Lazy eye /  / Migraine
 / Something in the eye /  / Other: /  / Other: /  / Retinal problems
 / Tearing / Other /  / Strabismus/Lazy eye
 / Vision problems /  / Other:

Occupation (or former work if retired):______

Current Medical Problems  None

Allergy / Endocrine / Hematologic / Neurologic
 / Asthma /  / Diabetes—diet controlled /  / AIDS/HIV /  / Anxiety
 / Eczema /  / Diabetes—medication controlled /  / Bleeding tendencies /  / Dementia
 / Seasonal allergies/Hay fever /  / Diabetes—insulin needed /  / Hepatitis B or Hepatitis C /  / Depression
Cardiac /  / Pituitary tumor /  / Sickle cell disease /  / Dizziness
 / Atrial fibrillation /  / Thyroid disease / Skin /  / Headache
 / Heart disease / Gastrointestinal /  / Breast cancer /  / Migraine
 / Heart surgery /  / Crohns disease /  / Hx of skin cancers /  / Parkinsons disease
 / High blood pressure /  / Ulcerative colitis /  / Psoriasis /  / Seizures
 / High cholesterol / Genitourinary / Musculoskeletal /  / Stroke
Ear, nose, mouth, throat /  / Genital sores /  / Back pain /  / Syphillis
 / Mouth sores /  / Prostate enlargement /  / Fibromyalgia / Respiratory
 / Pain with chewing /  / Lupus /  / COPD
 / Sinus congestion /  / Rheumatoid arthritis /  / Lung Cancer
 / TMJ problems /  / Sjogrens syndrome /  / Sleep Apnea
 / Tuberculosis

List All Medications: None History of taking Flomax

Medication Allergies: ______

______

Patient’s signature: Date:____

Doctor’s signature:______

REVISED 8/27/13

AUTHORIZATION FOR RELEASE OF INDIVIDUALLY IDENTIFIABLE
HEALTH INFORMATION TO DESIGNATED PARTY

This Authorization grants permission to the Designated Party(ies) named below to: make or confirm appointments; have access to x-ray, laboratory, or test findings; have access to telephone communication and answering machine messages as well as other common means of communication; pick up sample medications; be made aware of my condition, diagnosis, prognosis, and treatment plans; and have access to my financial health information.

I hereby authorize DuPage Ophthalmology, SC to disclose my individually identifiable health information as described above. I understand that this authorization is voluntary. I understand that once this information is released to the Designated Party(ies) named below, the released information may no longer be protected by federal privacy regulations.

Patient name: ______DOB: ______

Designated party ______Relationship to Patient:______

Address:______Phone: ______

Designated party ______Relationship to Patient:______

Address:______Phone: ______

Designated party ______Relationship to Patient:______

Address:______Phone: ______

The information will be used or disclosed for the following purposes:

 At the request of the individualOther: ______

Please read the three statements below carefully before signing this document:

  1. I understand that I may revoke this Authorization at any time by notifying the healthcare provider in writing; however, if I do revoke the authorization, it will not have any effect on any actions taken by the provider prior to their receipt of the revocation.
  1. I understand that my treatment cannot be conditioned on whether or not I sign this Authorization:

3. I understand that this Authorization will : (Must check one)

( ) expire 1 year from the date executed; or

( ) be effective for the lifetime of the patient unless revoked (see #1 above)

______

Signature of patient or patient’s representative Date

(Form will not be valid unless all appropriate blanks are filled)

Printed Name of Patient’s Representative:______

Relationship to Patient: ______

*YOU MAY REFUSE TO SIGN THIS AUTHORIZATION*

REVISED 8/27/13