eyesonevesham - Patient Form

PATIENT INFORMATION
Patient Name

Last NameFirst Name
Sex

MaleFemale
Birth Date

MonthDayYear
Address

Street Address

CityState

Zip Code
Home Phone #
Cell Phone
Preferred Phone

HomeCell
Employer
Occupation
Referred By
Email address
Signature

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INUSRANCE INFORMATION
Vision Plan Name
ID #
Primary (who the insurance is under)
Relationship

SelfSpouseChild
Insured Birthdate

MonthDayYear
Medical Plan Name
Medical ID #
MEDICAL AND OCCUR HISTORY
What is the reason for today's exam ?
Date of last exam

MonthDayYear
From
Do you or any blood relatives (Parents, Grandparents, Siblings) have any conditions ?

	Self	Relative	None
Diabetes
High Blood Pressure
Thyroid Problems
Heart Disease
Asthma
Cancer

	Self	Relative	None
Glaucoma
Cataracts
Retinal Disease
Eye Surgery
Eye Injury
Other

If other (please explain)

	Yes	No
Do you see double?
Frequent Headache?
Are you pregnant?
Are you nursing?
Eye been dilated ?
Primary Care Dr.

Please explain any positive finding
Are you taking any eye drops (prescription or over the counters) please list
Are you taking any other medication (prescription or over the counters) please list
Do you have any allergies (medications or other) ? Please list
Are you having any problems with your vision?

Far AwayUp CloseBoth
Are you planning on getting an update contact lens RX / getting any new contact lens?

YesNo

FINANCIAL POLICY
Eyes on Evesham, LLC

Your MEDICAL INSURANCE is billed for MEDICAL conditions (diabetes, red eyes) and your VISION plan is billed for VISION related services (glasses). These visits might also have to be billed over SEPERATE visits. These are the guidelines dictated by the insurance companies.

All professional services are non refundable.

I UNDERSTAND I AM RESPONSIBLE FOR KNOWING THE BENEFITS MY INSURANCE PROVIDES.

BY SIGNING BELOW, I HEREBY AUTHORIZE EYES ON EVESHAM, LLC, TO DISCLOSE ANY NECESSARY INFORMATION; TO ANY PHYSICIANS FOR THE PURPOSE OF PROVIDING CONTINUING PROFESSIONAL CARE AND TO ANY INSURANCE COMPANY/THIRD PARTY PAYER, FOR THE PURPOSE OF OBTAINING PAYMENT TO EYES ON EVESHAM, LLC FOR SERVICES PROVIDED.

I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO EYES ON EVESHAM, LLC.

IF PAYMENT IS DENIED BY THE INSURANCE COMPANY I AGREE TO BE PERSONALLY AND FULLY RESONSIBLE FOR PAYMENT.

BY SIGNING BELOW; I ACKNOWLEDGE AND ACCEPT THE TERMS AND CONDITIONS SET FORTH ON THIS FORM.
Patient Name (or Legal Guardian)
Signature

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AUTHORIZATION FOR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION
I hereby authorize the use or disclosure of my individually identifiable health information as described below. I understand that the information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal privacy regulations.
- Persons/organizations authorized to use or disclose the information: Office of Dr. Eyes on Evesham LLC (Practice Name)
- Persons/organizations authorized to receive the information: Target Optical
- Specific description of information that may be used/disclosed: My telephone number, email address and next appointment date(s) and time(s),
- As part of our recall program, the information might be used/disclosed for the following purposes:
  a) For the purpose of providing Targct Optical coupons and service and product information either from this office or directly from Target Optical; and
  
  b) To compare contact lists with Target Optical to help avoid duplicate contacts related to eye exam scheduling within similar time frames.
- I understand that this authorization is voluntary and that I may refuse to sign this authorization. My refusal to sign will not affect my ability to obtain treatment, receive payment or eligibility for benefits unless allowed by law.
- The organization authorized to use/disclose the information will receive compensation for doing so.
YesNo
- I understand that I may inspect or copy the information used or disclosed
- I understand that I may revoke this authorization at any time by notifying the person/organization providing the information in writing, except to the extent that:
  1. action has been taken in reliance on this authorization; or
  2. if this authorization is obtained as a condition for obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy.
Signature of patient or patient's representative

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Health Insurance Portability and Accountability Act, (HIPPA)
Patient's Name
By signing below, I acknowledge receipt or the opportunity to review the Notice of Privacy Practices of Eyes on Evesham, LLC. In addition by signing, I authorize Eyes on Evesham, LLC to disclose my health information in conformance with the provisions of the Notice of Privacy Practices.

I have the right to withdraw or revise my permission at any time in writing

To whom, other than yourself, may we speak to regarding your condition/results?
Name
Relationship
Name
Relationship
Name
Relationship
Signature

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DIGITAL RETINAL PHOTOGRAPHY
At Eyes On Evesham, doctor Gaithri Ramanathan, O.D., F.A.A.O. recommends optomap retinal imaging.

optomap retinal imaging:
- Provides the doctor with a 200-degree ultra-widefield scan of the retina to assess the health of your eye.
- Allows the doctor to detect the presence of ocular and systemic diseases.
- Will be permanently saved in your medical file, allowing the doctor to make important comparisons annually
- Is fast, easy, and comfortable.
optomap scans for ocular and systemic conditions including but not limited to:
- Age Related Macular Degeneration
- Glaucoma
- High Blood Pressure
- High Cholesterol
- Diabetes
- Retinal Holes, Tears, or Detachments
- Melanoma
Yes. I elect to have optomap retinal imaging today. I understand that the cost for the optomap is $35.00 and is not covered by insurance.I would like more information from the doctor about optomap.
CONTACT LENS POLICIES
A contact lens is a medical device in contact with the tissues in the eye; therefore, it must fit appropriately to maintain the health of your eyes. A contacts lens prescription can only be determined by the careful observation of the lens on the eye and the eye’s response to the lens on follow up visits. All contact lens prescriptions must be finalized within 3 months. Since follow up care is essential, it is your responsibility to schedule and keep appointments and follow all lens care instructions.

We will not finalize the contacts lens prescription until both the patient and doctor are satisfied with the fit and visual acuity of the contact lens.

A contact lens prescription is valid for one year. All patients are required by law to come in for annual contact lens evaluations and corneal evaluations before a contact lens prescription can be issued. This is necessary to ensure the patient’s eyes are healthy and the contacts are fitting well.

Contact lens prescription fees vary based on how complicated the evaluation will be. First time soft contact lens wearers can expect contacts lens fees to start at $65.

The consult fee for established soft contact lens wearers ranges from $45-$85 based upon the complexity of the evaluation.

Contact lens evaluations are a separate charge and NOT covered by your routine vision or medical insurance.
Cancellation/No Show Policy

Eyes on Evesham, LLC, requires a 24-hour notice for ALL cancellations.

By scheduling and confirming this appointment you are agreeing to our cancellation policy both as a new and established patient for all future visits.

There may be a fee assessed which is not covered by insurance and would be an out-of-pocket expense for cancellations without proper notice. If a cancellation is unavoidable, we do ask that you give us as much notice as possible so we may offer that appointment time to another patient.
- If you arrive later than 15 minutes after your scheduled appointment time, we may ask you to reschedule.
- After more than one cancellation or no show, we may require that you call the day of for an appointment.
- 2 “no show” appointments may result in discharge from therapy.
Patient name (or guardian)
Signature

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PATIENT INFORMATION

INUSRANCE INFORMATION

MEDICAL AND OCCUR HISTORY

Do you or any blood relatives (Parents, Grandparents, Siblings) have any conditions ?

FINANCIAL POLICY

Eyes on Evesham, LLC

AUTHORIZATION FOR THE USE AND DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION

Health Insurance Portability and Accountability Act, (HIPPA)

DIGITAL RETINAL PHOTOGRAPHY

CONTACT LENS POLICIES