Patient information
PATIENT INFORMATION
Date_____________
First Name_______________________M.I.______
Last Name________________________________
Address___________________________________
___________________________________________
City______________________State_______Zip_____
Sex M F age_____ Birthdate__________
single married divorced widowed
Patient SS#________________________
Occupation_______________________________
Employer__________________________________
Employer address______________________________
___________________________________________
___________________________________________
Employer phone___________________________
Who referred you to our office?
___________________________________________
INSURANCE INFORMATION
Who is responsible for payment on this account?
___________________________________________
Relationship to patient___________________
Insurance co.____________________________
ID #_____________________________________
Group #________________________________
Policy holder________________________________
Relationship to patient___________________
Policy holder Date of Birth________________
Policy holder SS#________________________
Secondary insurer_______________________
ID#_____________________Group__________
Policy holder____________________________
Relationship to patient___________________
Policy holder Date of Birth________________
Policy holder SS#________________________
CONTACT INFORMATION
Telephone numbers
Home_______________Work_____________________
Cell phone_________________Pager__________________
I prefer to be called at home work cell pager
Email address______________________________________
Whom can we contact in an emergency?
Name_____________________________________
Relationship_____________________
Phone number____________________________
Primary care physician:_______________________________
Last Physical____________
Address of physician_____________________________________
___________________________________________
Phone__________________Fax______________
YOU WILL BE ASKED TO PRESENT A CURRENT MAJOR CREDIT CARD AND DRIVER’S LICENSE AT THE TIME OF YOUR EXAM. This information will be kept secure in our computer. No hard copy of either document will be taken. It is needed for identification and guarantee of payment.
Would you like more information about any of the following?
contact lenses
vision therapy
corneal refractive therapy
new eyeglass frame styles
laser eye surgery
ultrathin eyeglass lenses
tinted contact lenses
sports vision
Patient medical history
EYE HEALTH HISTORY
Todays visit is for a:
medical eye problem
vision problem
routine check up
Reason for visit today_______________________________________
Date of last eye examination_________________
Name of Doctor________________________________
Do you wear eyeglasses? Y N
For what purpose?
full time distance vision near vision occasionally
other________________________________________
Do you wear contact lenses? Y N
Hard Gas perm Soft
Full time occasionally
Are you currently pregnant or nursing an infant Yes No
Are you a smoker Y N packs per day______
Alcohol consumption________________
Please check any of the
symptoms you currently have.
Bloodshot eyes
Blurred vision- distance
Blurred vision- near
Burning eyes
Chronic fever
Crossed or wandering eyes
Discharge from eyes
Dizziness, fainting, blackouts
Double vision
Dry eyes
Eye injury
Eye pain
Eye strain
Floaters or spots
Headaches
Itching eyes
Light flashes
Light sensitivity
Loss of vision
Poor night vision
Red eyes
Seeing haloes around lights
Temporary loss of vision
Twitching eyelid
Watering eyes
Weight loss/gain
What allergies do you have:
___________________________
___________________________
___________________________
Please check any of the problems you or a family member has had.
You Family
Blindness
Cancer
Cataracts
Crossed eyes
Eye infection
Eye injury
Eye surgery
Glaucoma
Lazy eye
Migraines
Poor color vision
Retinal problems
Wandering eye
list the medications you are currently taking and what they are used for
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Please check any of the conditions that apply to you or your family
You Family
Cardiovascular (Heart, HBP, stroke)
Respiratory(Asthma, emphysema, TB)
Gastrointestinal(colitis, Inflamm. Bowel)
Endocrine(Diabetes, thyroid)
Immunological(AIDs, HIV, lupus, Sjogrens,
arthritis, sarcoid, MS)
Urological(kidney, prostate)
Dermatological(rashes, dermatitis)
Musculoskelatal(joint, muscle pain, arthritis)
Neurological(epilepsy, paralysis)
Psychiatric(depression, anxiety, ADD)
Hepatic(liver disease, Hepatitis)
Blood diseases(sickle cell, bleeding)
Ear/Nose/Throat
Payment policy/Privacy statement
Payment Policy---Please read, sign and bring with you to exam
Payment Policy
Payment in full is expected for all services when they are rendered. A deposit of 50% must be paid for all ophthalmic materials (lenses, frames, contact lenses) before they can be ordered. Copayments for materials under vision plans are due in full before materials can be ordered. The balance due on any ophthalmic materials must be paid at the time materials are dispensed. Any warranties on materials take effect at the time they are ordered. It is the patient’s responsibility to pick up materials in a timely fashion and to return any materials before the warranty on these materials has expired. A late fee of 1% per month of the balance due will be charged to your account for all accounts more than 30 days past due. For accounts over 60 days past due: We reserve the right to automatically bill your credit card for any of these charges on your account unless other arrangements have been made. Account balances not billed to credit cards will be either turned over for collection or sent to small claims court. Any collection fees will be charged to your account as well.
Patients with insurance: Vision care insurance will typically cover routine vision care that is non-medical in nature. Medical insurance will typically cover medically related services. Some medical plans will allow annual or biannual routine exams. Your responsibility is as follows:
1. To present a valid insurance card at the time of your visit.
2. To identify whether your visit is routine or for a medical vision or eye problem. Your insurance company may require different testing documentation for different kinds of visits.
3. If you are coming in for a routine visit you must check with your insurance company to determine if you are currently eligible for routine vision care. If you are not eligible, you will be responsible for the full office visit charges at the time of your visit.
4. If your visit is for a medical eye or vision problem you must check whether your insurance requires you to present a referral for specialist visits. We are considered a specialist by all medical insurance plans. You are responsible for having this referral at the time of your visit so that we may submit the claim to your insurance for reimbursement. Should you not have the necessary paperwork at the time of your visit, you will be responsible for payment at the time of service, and for submitting the needed forms to your insurance company.
5. If you are coming in for a medical eye or vision problem your insurance company will only reimburse us for the medical portion of the testing. You will be billed separately for the refraction and any other part of the eye examination that is not covered. This fee will be collected at the time of your visit.
6. We submit all insurance forms electronically for payment within one day of the date of service. Any claims that have been verified as being received by your insurance company but not settled after 60 days will be transferred to the patient for payment. It is then your responsibility to follow up with your insurance company.
7. All applicable copayments, deductibles, or non-covered items (services and materials) must be paid for at the time of your visit. These are fees that your insurance company withholds from us and insists that we collect from you. Your insurance company makes no guarantee of payment even when they have given us authorization for services or materials, or when they have certified eligibility. You will be billed for any services or materials that are applicable following our receipt of an explanation of benefits from your insurance company
Medicare patients:
Medicare will pay 80% of the medical part of your examination today. This takes effect only after you have reached your deductible for the year. You are responsible for the balance of 20% unless this is covered by secondary or Medigap insurance. If Medicare has your secondary insurer on file, the claim will be automatically sent to your secondary insurer. If there is no secondary insurer on file with Medicare it is your responsibility to submit the 20% copayment to your secondary insurer. You will be responsible for the refraction charge at the time of visit, as this is not covered by either Medicare or Medigap policies. Medicare only reimburses toward the first pair of spectacles after cataract surgery. Otherwise all ophthalmic charges are your responsibility.
I have read and understand and agree to the above policies on this day
________________________.
-I hereby give Dr. Rothman authorization to submit assigned and non-assigned claims to my insurance carrier for any services provided to me by Dr. Rothman. I authorize the release of medical or any other information about me necessary to process any of the aforementioned claims.
-I understand and agree that in accepting treatment from Dr. Rothman, that I am ultimately responsible for all fees which occur as a result of care rendered to me or my child, regardless of whether they are covered by insurance.
♦I have been given an opportunity to review the privacy policies of this office and
□ I do not wish to at this time
□ I would like a copy of the policies
________________________________
name of person responsible for account
________________________________
signature
Payment Policy
Payment in full is expected for all services when they are rendered. A deposit of 50% must be paid for all ophthalmic materials (lenses, frames, contact lenses) before they can be ordered. Copayments for materials under vision plans are due in full before materials can be ordered. The balance due on any ophthalmic materials must be paid at the time materials are dispensed. Any warranties on materials take effect at the time they are ordered. It is the patient’s responsibility to pick up materials in a timely fashion and to return any materials before the warranty on these materials has expired. A late fee of 1% per month of the balance due will be charged to your account for all accounts more than 30 days past due. For accounts over 60 days past due: We reserve the right to automatically bill your credit card for any of these charges on your account unless other arrangements have been made. Account balances not billed to credit cards will be either turned over for collection or sent to small claims court. Any collection fees will be charged to your account as well.
Patients with insurance: Vision care insurance will typically cover routine vision care that is non-medical in nature. Medical insurance will typically cover medically related services. Some medical plans will allow annual or biannual routine exams. Your responsibility is as follows:
1. To present a valid insurance card at the time of your visit.
2. To identify whether your visit is routine or for a medical vision or eye problem. Your insurance company may require different testing documentation for different kinds of visits.
3. If you are coming in for a routine visit you must check with your insurance company to determine if you are currently eligible for routine vision care. If you are not eligible, you will be responsible for the full office visit charges at the time of your visit.
4. If your visit is for a medical eye or vision problem you must check whether your insurance requires you to present a referral for specialist visits. We are considered a specialist by all medical insurance plans. You are responsible for having this referral at the time of your visit so that we may submit the claim to your insurance for reimbursement. Should you not have the necessary paperwork at the time of your visit, you will be responsible for payment at the time of service, and for submitting the needed forms to your insurance company.
5. If you are coming in for a medical eye or vision problem your insurance company will only reimburse us for the medical portion of the testing. You will be billed separately for the refraction and any other part of the eye examination that is not covered. This fee will be collected at the time of your visit.
6. We submit all insurance forms electronically for payment within one day of the date of service. Any claims that have been verified as being received by your insurance company but not settled after 60 days will be transferred to the patient for payment. It is then your responsibility to follow up with your insurance company.
7. All applicable copayments, deductibles, or non-covered items (services and materials) must be paid for at the time of your visit. These are fees that your insurance company withholds from us and insists that we collect from you. Your insurance company makes no guarantee of payment even when they have given us authorization for services or materials, or when they have certified eligibility. You will be billed for any services or materials that are applicable following our receipt of an explanation of benefits from your insurance company
Medicare patients:
Medicare will pay 80% of the medical part of your examination today. This takes effect only after you have reached your deductible for the year. You are responsible for the balance of 20% unless this is covered by secondary or Medigap insurance. If Medicare has your secondary insurer on file, the claim will be automatically sent to your secondary insurer. If there is no secondary insurer on file with Medicare it is your responsibility to submit the 20% copayment to your secondary insurer. You will be responsible for the refraction charge at the time of visit, as this is not covered by either Medicare or Medigap policies. Medicare only reimburses toward the first pair of spectacles after cataract surgery. Otherwise all ophthalmic charges are your responsibility.
I have read and understand and agree to the above policies on this day
________________________.
-I hereby give Dr. Rothman authorization to submit assigned and non-assigned claims to my insurance carrier for any services provided to me by Dr. Rothman. I authorize the release of medical or any other information about me necessary to process any of the aforementioned claims.
-I understand and agree that in accepting treatment from Dr. Rothman, that I am ultimately responsible for all fees which occur as a result of care rendered to me or my child, regardless of whether they are covered by insurance.
♦I have been given an opportunity to review the privacy policies of this office and
□ I do not wish to at this time
□ I would like a copy of the policies
________________________________
name of person responsible for account
________________________________
signature