PATIENT INFORMATION Step 1 of 7 14% Primary reason for visit Today’s date: MM slash DD slash YYYY Patient’s name: First Last Mr. Mrs. Ms. Dr. Male Female Patient’s date of birth: MM slash DD slash YYYY Vision insurance/Member #:Cell phone:Medical insurance company: Home phone:Benefits #:E-mail: Policy Holder’s name: First Last Policy Holder’s date of birth: MM slash DD slash YYYY Policy Holder’s last 4 SS:Address Street Address City State / Province / Region ZIP / Postal Code REGARDING INSURANCE: If we are a contract provider for your vision insurance company, we will be happy to bill you insurance for you. If not, it is customary in the vision care profession that the patient is responsible for the entire fee at the time of the exam and the insurance company reimburses the patient. You should attach a copy of your fee slip to your insurance form and send it to your insurance company for reimbursment. If you have any questions, we will be happy to help you. Payment is due upon time of service.SPECTACLE/CONTACT LENS INFORMATIONDo you wear glasses? Yes No Do you wear contacts? Yes No What type of contact lenses soft hard (RPG) Brand: Previous contact RX:OD (right eye) OS (left eye) Base curve: Diameter: How often do you put in a fresh pair of contacts?: PERSONAL HEALTH INFORMATIONLast eye exam: MM slash DD slash YYYY Dilated? Yes No Eye doctor: Are you pregnant or nursing? Yes No SurgeryEye surgery: Other surgeries: Medications (including vitamins, asprin, oral contraceptives, over the counter, or eye drops): Add RemoveAllergies (medicine, food, or enviromental): Add RemoveDo you drink alcohol? Yes No mild moderate severe Do you use tobacco products? Yes No How often do you drink? Do you use illegal drugs? Yes No How often do you smoke? PERSONAL HEALTH INFORMATION CONTINUEDFlashes of light/Floaters yes no unsure Psoriasis yes no unsure Double vision (2 of everything) yes no unsure Skin cancer yes no unsure Dry eyes yes no unsure Sinus congestion/disease yes no unsure Burning yes no unsure Dry mouth/Throat yes no unsure Itchy eyes yes no unsure Cronic cough yes no unsure Fuzzy vision (not clear) yes no unsure Blood disorder yes no unsure Heart disease yes no unsure Anemia yes no unsure High Cholesterol yes no unsure Vascular problems yes no unsure High blood pressure yes no unsure Ankylosing spondylitis yes no unsure Diabetes yes no unsure type Arthritis yes no unsure Gout yes no unsure Downs syndrome yes no unsure Crohn’s disease yes no unsure Muscular dystrophy yes no unsure Thyroid problems yes no unsure Myasthenia gravis yes no unsure Renal/Kidney problems yes no unsure Headaches/migraines yes no unsure Pituitary problems yes no unsure Seizures yes no unsure IBD/IBS yes no unsure Psychiatric yes no unsure Gastrointestinal disorder yes no unsure Alzheimer’s yes no unsure AIDS/HIV yes no unsure Anxiety disorder yes no unsure Herpes simplex/Zoster yes no unsure Autism yes no unsure Lyme disease yes no unsure Brain Trauma yes no unsure Tuberculosis (TB) yes no unsure Depression yes no unsure Sarcoldosis yes no unsure Asthma yes no unsure Ocular rosacea yes no unsure Emphysema yes no unsure Bronchitis yes no unsure FAMILY HISTORYPlease notate any family history of the following including parents, grandparents, siblings, children, living and/or deceased in the following:EYE DISEASE/CONDITIONBlindness yes no unsure Relationship to you: Cataracts yes no unsure Relationship to you: Crossed eyes yes no unsure Relationship to you: Glaucoma yes no unsure Relationship to you: Macular degeneration yes no unsure Relationship to you: Retinal detachment/disease yes no unsure Relationship to you: SYSTEMIC DISEASE/CONDITIONArthritis yes no unsure Relationship to you: Cancer yes no unsure Relationship to you: Diabetes yes no unsure Relationship to you: Heart disease yes no unsure Relationship to you: High blood pressure yes no unsure Relationship to you: Kidney disease yes no unsure Relationship to you: Lupus yes no unsure Relationship to you: Thyroid disease yes no unsure Relationship to you: Other: Yes No Patient’s signature:(If patient is under 18 years old, parent signature is required.)Today’s date: MM slash DD slash YYYY ACKNOWLEDGEMENT OF HIPAA PRIVACY NOTICE AND DISCLOSURE AUTHORIZATIONBy signing this form, you acknowledge that Dr. Monica Cross has provided you with access to a copy of her Health Insurance Portability and Accountability Act (HIPAA) Privacy Notice, which explains how your health information will be handled in various situations. By law, we are required to have you sign this form annually or when any of the contact information that you wish for us to communicate with regarding your health information has changed. The practice has provided me access to HIPAA Privacy Notice. I understand I may request a copy for my personal use. I acknowledge that I have read, understand and agree to the above.Patient’s Signature: (If patient is under 18 years old, parent signature is required.)Today’s date: MM slash DD slash YYYY CONSENT FOR RETINAL PHOTOGRAPHYWhen indicated the doctor will need to examine the internal structures of the eye in greater detail for signs of disease. Indicators might include diabetes, high blood pressure, complaints of fl ashes, fl oaters, side vision loss, high prescription, one seeing eye, history of trauma, or you are not correcting to 20/20 during the exam. Examination of the internal structures in greater detail is done using pupillary dilation or retinal photography. Retinal photography takes a quick picture of the internal structures of the eyes. Dilation drops are usually not needed. With retinal pictures the patient leaves seeing exactly as they did when they walked into the offi ce. In addition the pictures are permanent part of your record from which to refer to in order to monitor the health of your eyes in subsequent years. The images will be shared with you during your visit. The cost is $39 dollars if your insurance does not cover it.Patients reserve the right to refuse any test or diagnostic procedure recommended. If a patient refuses they assume all the risk for potentially not detecting any serious eye condition.Do you want this procedure? RETINAL PHOTO ACCEPT DECLINE Patient’s signature:(If patient is under 18 years old, parent signature is required.)Today’s date: MM slash DD slash YYYY PATIENT FINANCIAL AND PRACTICE POLICIESThe patient must provide current, accurate billing/patient information. Inaccurate information will result in all charges for services becoming the sole responsibility of the patient/responsible party. Patients must notify the practice of any changes in information (adress, insurance, and phone numbers) and provide insurance cards at each visit for verification.Copayments are to be paid at the time services are rendered. No refunds of professional services will be given. Self-pay patients: We welcome patients with or without health or vision insurance. All services must be paid in full at time of service. It is the responsibility of the patient to pay any outstanding bills promptly. Once an account becomes delinquent, it will go to our collection agency.Dr. Cross is happy to preform a contact lens fit for Kimbrough Eye Clinic patients for contact lenses with an eye glass prescription from Kimbrough that has been done within the last 30 days.Additional fees (These may not apply to you!): Completion of an MVA vision certificate is $20 Accompanying visual field test for MVA vision certificate is $20 Completion of any form pertaining to school, employment, etc is $15 We charge a fee for copying medical records. The state of Maryland allows a fee for copying records not to exceed .76 cents for each page, plus the actual cost of postage, handling, and preperation fee of $23, if the records are sent to another provider. A medical release form must be completed and signed by the patient before any records will be copied, faxed, or released. By signing I understand the above policies.Patient’s Signature:(If patient is under 18 years old, parent signature is required.)Today’s date: MM slash DD slash YYYY RESPONSIBILITY STATEMENTYour insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them not with our office. It is your responsibility to pay in advancefor the deductible, coinsurance, or any other balances not paid for by your insurance. We will assist you in receiving reimbursement as much as possible, but you are responsible in advance for your bill.AUTHORIZATION TO RELEASE MEDICAL INFORMATIONI authorize any holder of medical information about me to release the Health Care Financing Administration and its agents any information needed to determine benefits or the benefits payable for related services. This assignment will remain in effect until revoked in writing. A photocopy of this assignment is considered to be as valid as the original.FINANCIAL RESPONSIBILITY / MEDICAL RELEASE By signing this statement you agree to be financially responsible for all charges and to have your information shared for insurance benefit varification.Patient’s Signature:(If patient is under 18 years old, parent signature is required.)Today’s date: MM slash DD slash YYYY PATIENT SCREENING FORMYou have come to our office today for a routine eye exam and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following.While our office complies with the State Health Department and the Center for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus we cannot make any guarantees. Our staff are symptom free and, to the best of their knowledge, have not been exposed to the COVID-19 virus. However, since we are a place of public accomodation, other persons (inculding other patients) could be infected, with or without their knowledge.In order to reduce the risk of spreading COVID-19, we are asking you a number of screening questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.PLEASE ANSWER TO THE FOLLOWING QUESTIONS:Have you had COVID-19? Yes No when? MM slash DD slash YYYY Are you currently awaiting the results of a COVID-19 test? Yes No Do you have a fever? Yes No Do you have any shortness of breath? Yes No Do you have a dry cough? Yes No Do you have a runny nose? Yes No Do you have a sore throat? Yes No Do you have sneezing, watery eyes, and/or sinus pain or pressure that is unusual and not related to seasonal allergies? Yes No Have you experienced unexplainable headaches, fatigue, or weakness? Yes No Have you lost your sense of taste and/or smell? Yes No Within the last 14 days, have you traveled to any foreign country? Yes No Within the last 14 days, have you traveled within the United States? Yes No where? Patient’s Signature:(If patient is under 18 years old, parent signature is required.)Today’s date: MM slash DD slash YYYY PATIENT’S TEMPERATURE:TAKEN BY: CANCELLATION / NO SHOW POLICYOur office reserves the right to charge a $25 FEE PER SCHEDULED APPOINTMENT if the patient misses an appointment or cancels without a 24 hour notice. It is our mission to provide appointment availabilty to everyone in the community on Fort Meade. If you make an appointment and you do not keep it you have now taken that opportunity from another Service Member or their familyIf you would like to know more about the TRICARE policy on no shows and cancelations please scan the link provided with your cell phone’s camera.