Patient Paperwork

Date:

Date

Patient Name:

Date of Birth

Date

Age:

Sex:

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Physical Address

Street Address Line 2

CityState

Zip Code

Preferred Phone Number:

Alternate Phone Number:

Email:

example@example.com

Preferred Language:

Race:

Ethnicity:

Preferred method to receive appointment reminders

Phone CallTextEmail

Parent/Guardian Information 1:

First NameLast Name

SSN of Parent/Guardian 1

DOB of Parent/ Guardian 1

Date

Relationship of Parent/Guardian 1 to Patient

Parent/Guardian Information 2:

SSN of Parent/Guardian 2

DOB of Parent/Guardian 2

Date

Relationship of Parent/Guardian 2 to Patient

Emergency Contact:

Emergency Contact Phone Number:

Emergency Contact Relationship to Patient:

Primary Medical Insurance Company:

Primary Medical Insurance ID Number:

Primary Medical Insurance Group Number:

Name of Insured/Policy Holder

First NameLast Name

DOB of Policy Holder

Date

SSN of Policy Holder

Relationship to Patient

Secondary Medical Insurance Company:

Secondary Medical Insurance ID Number

Secondary Medical Insurance Group Number

Name of Insured/Policy Holder:

DOB of Policy Holder

Date

SSN of Policy Holder

Relationship to Patient:

Financial Agreement

Thank you for choosing us for your eye care. We are committed to providing you with quality and affordable health care. Some of our patients have had questions regarding patient and insurance responsibility for services rendered, so we have developed this financial agreement. Once you have finished reading please sign in the space provided. A copy will be provided to you upon request.

1. Insurance: We participate in most insurance plans, including Medicare. An up-to-date insurance card is expected at each visit. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payments and deductibles: All co-payments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company.

3. Non-covered services: Please be aware some - and perhaps all - of the services you receive may be noncovered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

4. Proof of insurance: All patients must complete our patient information from form before seeing the doctor. We must obtain a copy of your driver’s license and current valid insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

5. Claims submission: We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company we are not party to that contract.

6. Coverage changes: If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits. If your insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

7. Nonpayment: If your account is over 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may will refer your account to a collection agency.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Please let us know if you have any questions or concerns.

Printed Name

TODAY'S Date

Date

Signature

Relationship to Patient

Do you give us permission to communicate with your child's school about their care?

YesNo

Dear patient,

Your privacy is very important to us. We need your permission to speak to anyone regarding your care and medications. Please list below any family members or healthcare providers who may contact us about your current medications or care, including special doctors or therapists. We will also need your signature giving us written permission to communicate with the individuals you list below.

Family Member/Healthcare Provider We May Contact

I give Alaska Children's Eye and Strabismus permission to discuss my current care and medications with the individuals or organizations listed above.

Printed Name

Date

Signature

Relationship to patient

Patient Name:

Referred by:

Pediatrician/Medical Providers:

Preferred Pharmacy and Location:

Our Electronic Medical Records can “pull” your medication list from your preferred pharmacy if you’d like. This helps avoid potential drug interactions.

I consent to link my information with ACES EMR.I decline to link my information.

Does the patient wear glasses?

YesNo

How old are the glasses?

Patient's Medical History

Please Specify Other Conditions

Family Medical History

Present Medications (If you have a list please provide):

Present Medications Continued

Allergies

Allergies Continued