PATIENT INFORMATION

Step 1 of 7

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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 INFORMATION

Do you wear glasses?

Yes

Do you wear contacts?

Yes

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:

MM slash DD slash YYYY

Dilated?

Yes

Eye doctor:

Are you pregnant or nursing?

Yes

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

mild

moderate

severe

Do you use tobacco products?

Yes

How often do you drink?

Do you use illegal drugs?

Yes

How often do you smoke?

PERSONAL HEALTH INFORMATION CONTINUED

Flashes of light/Floaters

yes

unsure

Psoriasis

yes

unsure

Double vision (2 of everything)

yes

unsure

Skin cancer

yes

unsure

Dry eyes

yes

unsure

Sinus congestion/disease

yes

unsure

Burning

yes

unsure

Dry mouth/Throat

yes

unsure

Itchy eyes

yes

unsure

Cronic cough

yes

unsure

Fuzzy vision (not clear)

yes

unsure

Blood disorder

yes

unsure

Heart disease

yes

unsure

Anemia

yes

unsure

High Cholesterol

yes

unsure

Vascular problems

yes

unsure

High blood pressure

yes

unsure

Ankylosing spondylitis

yes

unsure

Diabetes

yes

unsure

type

Arthritis

yes

unsure

Gout

yes

unsure

Downs syndrome

yes

unsure

Crohn’s disease

yes

unsure

Muscular dystrophy

yes

unsure

Thyroid problems

yes

unsure

Myasthenia gravis

yes

unsure

Renal/Kidney problems

yes

unsure

Headaches/migraines

yes

unsure

Pituitary problems

yes

unsure

Seizures

yes

unsure

IBD/IBS

yes

unsure

Psychiatric

yes

unsure

Gastrointestinal disorder

yes

unsure

Alzheimer’s

yes

unsure

AIDS/HIV

yes

unsure

Anxiety disorder

yes

unsure

Herpes simplex/Zoster

yes

unsure

Autism

yes

unsure

Lyme disease

yes

unsure

Brain Trauma

yes

unsure

Tuberculosis (TB)

yes

unsure

Depression

yes

unsure

Sarcoldosis

yes

unsure

Asthma

yes

unsure

Ocular rosacea

yes

unsure

Emphysema

yes

unsure

Bronchitis

yes

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

unsure

Relationship to you:

Cataracts

yes

unsure

Relationship to you:

Crossed eyes

yes

unsure

Relationship to you:

Glaucoma

yes

unsure

Relationship to you:

Macular degeneration

yes

unsure

Relationship to you:

Retinal detachment/disease

yes

unsure

Relationship to you:

SYSTEMIC DISEASE/CONDITION

Arthritis

yes

unsure

Relationship to you:

Cancer

yes

unsure

Relationship to you:

Diabetes

yes

unsure

Relationship to you:

Heart disease

yes

unsure

Relationship to you:

High blood pressure

yes

unsure

Relationship to you:

Kidney disease

yes

unsure

Relationship to you:

Lupus

yes

unsure

Relationship to you:

Thyroid disease

yes

unsure

Relationship to you:

Other:

Yes

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 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:

MM slash DD slash YYYY

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

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 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:

MM slash DD slash YYYY

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:

MM slash DD slash YYYY

PATIENT SCREENING FORM

You 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

when?

MM slash DD slash YYYY

Are you currently awaiting the results of a COVID-19 test?

Yes

Do you have a fever?

Yes

Do you have any shortness of breath?

Yes

Do you have a dry cough?

Yes

Do you have a runny nose?

Yes

Do you have a sore throat?

Yes

Do you have sneezing, watery eyes, and/or sinus pain or pressure that is unusual and not related to seasonal allergies?

Yes

Have you experienced unexplainable headaches, fatigue, or weakness?

Yes

Have you lost your sense of taste and/or smell?

Yes

Within the last 14 days, have you traveled to any foreign country?

Yes

Within the last 14 days, have you traveled within the United States?

Yes

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 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