Stang Family Eye Care - Patient Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date Of Birth*

Date

SS# or Last 4 Digits*

Home Phone*

Area CodePhone Number

Cell*

Area CodePhone Number

Work*

Area CodePhone Number

Employer/Application*

Date of last eye exam*

Date

By whom*

Who is your family doctor? *

Do you wear contacts?*

YesNo

If no, would you like to try contacts?

YesNo

Please check any condition that applies to you or any members of your immediate family:

	Self	Family
Diabetes
Retinal Detachment
High Blood Pressure
Eye Surgery
Cataracts
Lazy Eye
Heart Problems
Double Vision
Respiratory Problems
Blindness
Thyroid Problems
Head/Eye Injury
Glaucoma
Headaches
Loss of Vision

Please list your current medications

Allergies (please list)

1. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to _Stang Family Eyecare_, for services furnished me by _Slang Family Eyecare_. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the CMS-1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown.

_Stang Family Eyecare_ accepts the charge determination of the Medicare carrier as the full charge, and I am re.sponsible only for the deductible, coinsurance and nOncovered seivices. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier.

2. MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item9 of the CMS-1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that ptment of authorized secondary insurance benefits be made on my behalf to _Stang Family Eyecare_, if possible or otherwise to me. _

3. RELEASE OF INFORMATION: _ Stang Family Eyecare_ may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, -or HIV, to any person or corporation (1) which is or may be liable or under contract to _Stang Family Eyecare_ for reimbursement for services rendered, and (2) any health care provider for continued patient care. _Stang Family Eyecare_ may also disclose on an anonymous basis any .information concerning my case, which is necessary or appropriate for the advancement of medical science, medical education, medical research, for the collection of statistical data or pursuant to State or Federal law, statute or regulation. A copy of this authorization may be used in place of the original.

4. OTHER INSURANCE: I understand that _Stang Family Eyecare_ maintains a list of health care service plans with which it contracts. A list of such plans is available from the business office and that _Stang Family Eyecare_ has no contract, expressed or implied, with any plan that does not appear on the list. The undersigned agrees that I am individually obligated to pay the full charges of all services rendered to me by _Stang Family Eyecare_ if I belong to a plan that does not appear on the above-mentioned list.

5. NON-COVERED SERVICES: I understand that _Stang Family Eyecare_'s contracts with health care service plans (i.e., HMOs, PPOs) relate only° to items and services which are covered by the health care service plans. Accordingly, the undersigned- accepts full financial responsibility for all items or services, which are determined by the health care service plans not to be covered. Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient's contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient and treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with _Stang Family Eyecare_ to obtain necessary health care service plan authorizations.

6. FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by _Stang Family Eyecare_, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to _Stang Family Eyecare_ for payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney's fees as established by the court and not by a jury in any court action, I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to _Stang Family Eyecare_. If copayments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to _Stang Family Eyecare_. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill.

Beneficiary Signature or Authorized Party*

Date*

Date

PATIENT INFORMATION

VISUAL AND MEDICAL HISTORY

MEDICATIONS AND ALLERGIES

Signature on File, Assignment of Benefits, Financial Agreement