Primary reason for visit

Today’s date:

Patient’s name:

First Last

Mr.

Mrs.

Ms.

Dr.

Male

Female

Patient’s date of birth:

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:

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 INFORMATION

Do 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 INFORMATION

Last eye exam:

Dilated?

Yes

No

Eye doctor:

Are you pregnant or nursing?

Yes

No

Surgery

Eye surgery:

Other surgeries:

Medications (including vitamins, asprin, oral contraceptives, over the counter, or eye drops):

Allergies (medicine, food, or enviromental):

Do 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 CONTINUED

Flashes 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 HISTORY

Please notate any family history of the following including parents, grandparents, siblings, children, living and/or deceased in the following:

EYE DISEASE/CONDITION

Blindness

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/CONDITION

Arthritis

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:

ACKNOWLEDGEMENT OF HIPAA PRIVACY NOTICE AND DISCLOSURE AUTHORIZATION

By 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:

CONSENT FOR RETINAL PHOTOGRAPHY

When 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:

PATIENT FINANCIAL AND PRACTICE POLICIES

The 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:

RESPONSIBILITY STATEMENT

Your 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 INFORMATION

I 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:

CANCELLATION / NO SHOW POLICY

Our 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 family

If 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.

PATIENT INFORMATION

SPECTACLE/CONTACT LENS INFORMATION

PERSONAL HEALTH INFORMATION

Surgery

PERSONAL HEALTH INFORMATION CONTINUED

FAMILY HISTORY

EYE DISEASE/CONDITION

SYSTEMIC DISEASE/CONDITION

ACKNOWLEDGEMENT OF HIPAA PRIVACY NOTICE AND DISCLOSURE AUTHORIZATION

CONSENT FOR RETINAL PHOTOGRAPHY

PATIENT FINANCIAL AND PRACTICE POLICIES

RESPONSIBILITY STATEMENT

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

FINANCIAL RESPONSIBILITY / MEDICAL RELEASE

PATIENT SCREENING FORM

CANCELLATION / NO SHOW POLICY

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Fort Meade Family Eye Care