New Patient Packet

Welcome To Our Practice
We look forward to meeting you and caring for your eyes. Below you will find a list of items that we require for your next visit:
1. Bring your Medical and Vision Insurance cards-we cannot bill your insurance company without them.
2. Bring your driver's license or some form of picture ID (if you do not have a driver's license).
3. Make certain a referral has been generated if you have an HMO (or a Point of Service that requires one).
4. Bring your eyeglasses even if you wear contact lenses.
5. Wear your contact lenses (if applicable) if you would like us to renew your current prescription. Please bring any information that you might have on your current contacts.
Co-payments, refraction and contact lens fittings/evaluation fees: are due on the date of service.

Contact Lens Services: Please notify us in advance if you currently wear contact lenses or wish to be fitted for them. We need to allow the proper amount of time for this kind of appointment. There is an additional charge for contact lens fittings and evaluations.

Medical Exams: If your visit is for a known or suspected eye disease or injury, we will bill your medical insurance.

Routine Exams: If your visit is routine, (new glasses), we will bill your vision Plan.

Optical: If you are interested in eyewear, we have a large selection at very competitive prices. Come in and browse our optical during your visit. Our optical participates with many vision insurance plans, including Blue Cross Vision, DMC Heritage Optical, MEBS, MECA, VSP, Vision Care Plan, EyeMed {Select and Access Plans), Aetna Vision, and Harrington UMR Vision.

Just a note: We do our best to understand the many insurance benefits that our patients carry. Of course the expert about your own plan should be you! Please become familiar with your insurance so that you understand referrals (if required), co-pay and benefit levels. Your knowledge assists us in submitting a claim on your behalf. We promise to do our best to make your visit in our office as pleasant and convenient as possible.

Please complete the enclosed pre-registration forms and return them in our self-addressed stamped envelope.

Sincerely,

Gregory B. Fitzgerald, M.D.

Jacob Diskin, M.D.

Bianca Bilek, O.D.

And Staff
Vision Insurance VS Medical Insurance
What is the difference? We hope we can clarify this question for you.

Your vision insurance is a "rider" that either you or your employer purchases to receive coverage for a routine eye exam and glasses or contact lenses. Medical insurance is intended to cover services when a medical condition exists.

How do I know if my visit is medical or vision?

Your vision insurance would apply for a routine eye examination if you:
- Have no known problems with your eyes except for needing new glasses.
AND
- Were not referred by another physician.
AND
- Your previous eye examinations by Dr. Fitzgerald, Dr. Diskin or Dr. Bilek did not show any medical conditions.
If the above does not apply then we need to address the medical condition and use your medical insurance.

Examples of medical conditions: Cataracts, glaucoma or suspicion of glaucoma, macular degeneration, implants, red eyes, tearing, irritation, pain, etc.

Dr. Bilek, our optometrist, will see our patients for routine vision exams and contact lens appointments. Patients will be referred by Dr. Bilek to our ophthalmologists if there is a medical diagnosis. Our patients will continue to be under the care of our ophthalmologists Dr. Diskin and Dr. Fitzgerald for any medical conditions.
Patient Information
Name*

First NameLast Name
Title*
Birthdate*

MonthDayYear
Date
Social Security Number
Home Phone*
Cell Phone*
Preference *
Email*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Employer*
Phone Number*
Emergency Contact*
Alternate Phone
Phone*
How Did you Hear About our Office?*
Primary Care Physician*
Primary Care Physician Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Medical Insurance
Subscriber's Name*
Relationship to Patient*
Birthdate*
Social Security #*
Home Phone*
Cell Phone*
Subscriber's Employer*
Work Phone*
Insurance*

MedicareOther
Secondary Medical Insurance
Subscriber's Name
Relationship to Patient
Birthdate
Social Security #
Home Phone
Cell Phone
Subscriber's Employer
Work Phone
Insurance

MedicareOther
Vision Insurance or Other Insurance
Subscriber's Name
Relationship to Patient
Birthdate
Social Security #
Home Phone
Cell Phone
Subscriber's Employer
Work Phone
Insurance

MedicareOther
Guarantor Information
Is the Guarantor the same as patient? (The guarantor is the person financially responsible for the account. If the patient is a minor, the patient cannot be their own guarantor. In most other instances, the patient would be their own guarantor. The guarantor must be the person who signs the financial policy portion of this form.)*

YesNo
Guarantor's Name*
Relationship to Patient*
Birthdate*
Social Security #*
Home Phone*
Cell Phone*
Employer*
Work Phone*
Financial Policy
I hereby authorize the release of the necessary medical information to process claims and direct payment of benefits to Clavenna Vision Institute. I understand I am responsible to pay all non-covered services, co-pays, and deductibles. I understand if my insurance requires a referral authorization and I fail to bring a referral, I will be responsible for all charges. If my account falls in arrears, I agree to reimburse Clavenna Vision Institute the fees of any collection agency at a maximum percentage of 26% of the debt, and all costs and expenses, including reasonable attorney fees, associated with such collection efforts. I understand and agree to this financial policy.
Signature of Patient, Guarantor (if patient is a minor), Legal Guardian or Legal Representative*

Clear
Date*

MonthDayYear
Date
Effective 2018- our preferred method of communication for appointment reminders, recalls, eyeglass and contact lens order receipt is to use our automated text and email solution. If you have questions about this service, please ask our reception staff. We NEVER sell or share your email or cell phone information with anyone. All communication you receive in this format is related to your care or information about our office. If you wish to opt out, please check below.

Opt Out

This signature page is designed for you to establish limitations on what information we can share with people other than your insurance company or Drs. who coordinate your care. If you have certain family members or caregivers that normally assist you in either your health care decisions or financial decisions, you may wish to include them in Section "A" of this form. If you do not authorize anyone in section "A" be aware that we will not be allowed to answer any questions regarding your care, including billing, to anyone but you (including your spouse, siblings, adult children, and caregivers).
AUTHORIZATION TO RELEASE RECORDS

I AUTHORIZE THE PERSON(S) NAMED BELOW TO DISCUSS MY CARE IN MY ABSENCE AND OBTAIN MY MEDICAL RECORDS IF NECESSARY. (THIS DOES NOT INCLUDE DOCTORS WHO ARE INVOLVED IN MY CARE). I UNDERSTAND THIS AUTHORIZATION IS IN EFFECT VOKE THE AUTHORIZATION IN WRITING.
DESCRIPTION OF THE SPECIFIC INFORMATION TO BE DISCLOSED: *
ALL MEDICAL RECORDS*

YesNo
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Patient Signature *

Clear
Date*

MonthDayYear
Date

NOTICE OF PRIVACY PRACTICES
Please view our privacy practices here.
I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal health care operations such as quality assessments and physician
  certifications.
I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.
Patient Name*
Relationship to Patient
Signature*

Clear
Date

MonthDayYear
Date

A Patient-Centered Medical Home is a Partnership Between the Patient and Their Physicians
By being a part of a Patient-Centered Medical Home, your Primary Care Physician will:
- Work with you to improve your health
- Review your medications at every visit and recommend changes if needed
- Develop a plan with you to improve your health and manage any chronic health problems
- Set health goals with you and monitor your progress to help you stay healthy
- Use computer technology as needed to optimize your care
- Inform you of all test results in a timely manner
- Provide you with education material and information about community programs that will help you improve your health
- Provide 24 hour phone access to a medically trained professional(doctor, nurse or other providers)
- Work with after-hours care centers to be informed of your visit with 24 hours
- Offer same day appointments when needed
By choosing to participate in a Patient Centered Medical Home, I agree to:
- Make sure my doctor knows my entire medical history
- Tell my doctor all of the medications I am taking
- Actively participating with my doctor in planning my care
- Keep my appointment as scheduled
- Follow my doctor’s recommendations
- Frequently sign into my patient medical portal to update my medical history, review messages, and communicate with my provider(s) when necessary
- Ask my doctor questions about things I do not understand
- Ask my Primary Care Physician for advice before scheduling with a specialist
- Ask other health care providers to send my doctor information such as lab or test results, x-rays, or treatment notes
- Understand my insurance, what it coversand update the office with changes
- Provide the office feedback on how theycan improve my care
Being a part of a Patient-Centered Medical Home Neighborhood, your Ophthalmologist will:
- Communicate with your Primary care physician about treatment plans, medications, test ordered and test results
- Support the treatment plans and health goals set by your Primary Care Physician
- Have an agreement with your Primary Care Physician regarding who will have the lead responsibility for your care if achronic disease exists
- Have same day appointments available for urgent problem and appointments within1-3 weeks available depending on your medical needs
- Work with your Primary Care Physician to coordinate all aspects of your care
Patient Name*

First NameLast Name
Signature

Clear
Should be Empty:

	Yes/No	Relation (if grandparent, list maternal of paternal)	Living
Arthritis
Blindness
Cancer
Cataracts
Diabetes
Glaucoma
Heart Disease
High Blood Pressure
Kidney Disease
Lazy Eye
Macular Degeneration
Retinal Disease
Stroke
Tuberculosis

Welcome To Our Practice

Vision Insurance VS Medical Insurance

Patient Information

Primary Medical Insurance

Secondary Medical Insurance

Vision Insurance or Other Insurance

Guarantor Information

Financial Policy

Past Medical, Family, Social History and Review of Symptoms

Review of Systems

NOTICE OF PRIVACY PRACTICES

A Patient-Centered Medical Home is a Partnership Between the Patient and Their Physicians