PATIENT INFORMATION FORM

SingleMarriedPartnerDivorcedWidowedOther

INSURANCE INFORMATION (Please have insurance cards ready to copy)

Did you serve in the military?Y N

Are you covered under an employer? Are you covered under another healthcare plan? Y N

Is your spouse/family member employed?

Are you here from an injury at work? Y N Are your injuries accident related?

Did you find US onFacebookRealSelfOther GoogleInstagram

Other Specialist Doctors (cardiology, endocrine, cancer, plastic surgery, etc):

Confidential Medical History Form Fante Eye & Face Centre

Do you take blood thinners? Do you have a Pacemaker or other implanted device? 1. Please list all medications you take on a regular basis: (Please include any eye drops, vitamins, herbs, or over the counter products such as aspirin or aspirin containing products Frequency

2. Please list all illnesses/diseases which you have had or have now:

3. Please list all prior surgeries or procedures:

4. Please list any allergy or sensitivity to medication or food:

Have you fully completed your Covid-19 vaccination?

Confidential Medical History - page 1

5. Has anyone in your family had the same problem that brings you to our office? [YesNo [ I If yes, who? Do any of these diseases run in your family. If YES, please note relationshipGlaucma Do you smoke? If YES, how much? Diabetes

High blood pressure Skin cancer

6. Do any of the following problems apply to you? If YES, please explain.

Constitutional (fever, weight loss, poor appetite, etc Eyes (glaucoma, cataract, lazy eye, retina problems, etc)

Ear/Nose/Throat (hearing loss, sinus problems, sore throat, frequent bloody noses, etc) Cardiovasc (heart problems, chest pain, high blood pressure, stroke, pacemaker, heart surgery) Respiratory (asthma, shortness of breath, wheezing, coughing, etc) Gastro-intestinal (heartburn, diarrhea, vomiting, abdominal pain, etc) Genito-urinary (urinary problems, blood in urine, etc)

Skin (skin rashes, excessive dryness, used accutane, skin cancer/diseases, etc) Musculoskeletal (muscle aches,joint pain, swollen joints, artificial joint, arthritis, etc) Neurological (numbness, weakness, paralysis, headaches, spasm, MS, etc) Hematologic (blood disorders, leukemia, easy bleeding/bruising, take aspirin, etc) Allergy (hay fever, seasonal allergies, etc)

Endocrine (thyroid or pituitary problems, etc)

Psychiatric (depression, anxiety, etc)

Hepatitis B or C, HIV or AIDS, Tuberculosis, etc Diabetes, radiation treatments, anesthesia problems, etc.

Confidential Medical History - page 2

Fante Eye & Face Centre 4500 Cherry Creek Drive S, Suite 550 Denver, CO 80246

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding 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 health care providers who many be involved in that treatment directly and indirectly.

Obtain payment from third party payers.

Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, and read and understand 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 listed above to obtain a current copy of the Notices of Privacy 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.

I approve the following people to discuss my medical records & care with Fante Eye & Face Centre:

I attempted to obtain the patient's signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

Financial Policies Fante Eye and Face Centre 4500 Cherry Creek Drive South, Suite 550 Denver, Colorado 80246 Payment is expected at the time of service for all non-contracted fees. Arrangements must be made prior to seeing the physician if an account balance is anticipated. I understand that I am financially responsible for all charges whether or not they are covered by insurance. Private Insurance All private health insurance plans represent a contract between you and the insurance company. These contracts are not between the physician and the insurance company. As a courtesy, we will bill your insurance for all services rendered, but we are not responsible if your insurance does not pay. Instead, it is your responsibility to make certain that your insurance makes prompt payment, and to handle any disputes or questions that may arise.

or replacement plan. We will bill your Medicare supplement after Medicare has paid, if you provide the necessary information to us. Surgery Center Requirements If a surgery is planned at a surgery center, I understand and accept the responsibility to have preoperative clearance, labs, and EKG performed by my PCP, according to the requirements of the surgery center.

(initial) If I have not yet met my deductible, I agree that there is a $500 deposit due upon scheduling surgery

(initial) If I cancel a medical surgery within one month of the scheduled date, I will owe a $500 cancellation fee. Insurance will not

If we participate with your insurance carrier, we will accept assignment on all covered services and bill your insurance for you. You are responsible for the copay, deductible, and all non-covered services. Depending upon your particular benefits package with your insurance, they may cover some, all, or none of the services rendered to you. Therefore it is your responsibility to: 1. Provide documentation of your coverage 2. Know what benefits are covered by your insurance and what services are your personal responsibilities. 3. Provide the appropriate documents (e.g. referrals) that allow us to bill your insurance carrier. If the appropriate information is not received, you will be asked to sign a waiver of responsibility.

Rarely, after complete healing from surgery for which insurance has paid, you and your surgeon may agree that some revision procedure would enhance your cosmetic outcome. I understand that aesthetic surgery is not a covered benefit of Medicare and other insurance carriers. Therefore any aesthetic procedure will be my financial responsibility and payment in full will be expected prior to the procedure. Medical Authorization Release - By signing below, I authorize Fante Eye and Face Centre to give me reasonable and proper medical care by today's standard. I agree that the attending physician may use, or permit other persons to use any negatives, prints, movies, and digital images, and/or other visual or audio recordings, for purposes including, but not limited to, dissemination to health care professionals and/or members of the public for treatment, research, medical or scientific teaching, or other purposes in such a manner as may be deemed appropriate by my attending physician. I agree that this information may be used in either paper form or digital form. - I hereby authorize Fante Eye and Face Centre to release any medical or other necessary information to insurance carriers in either paper or digital from concerning this illness/accident. I hereby irrevocably assign all payments for all services rendered to Fante Eye and Face Centre. I also request payment of government benefits either to myself or to Fante Eye and Face Centre. I have read and understand the policies described above. I have provided complete and accurate medical and financial information on all forms. I acknowledge that I am responsible to pay all charges for treatment as outlined above. A copy of this authorization shall be considered valid as the original.

We accept Medicare assignment, which means that we accept the allowable charges set by Medicare. Medicare typically pays 80% of the allowable charge after your deductible has been met. You will be responsible for the 20% remainder unless you have a Medicare supplement