kimdoanmd.com - NEW PT PACKET

PATIENT PARTNERSHIP PLAN
Dear Patient,

Welcome to our practice. We intend to provide you with care and service that you expect and deserve. Achieving your best possible health requires a “partnership” between you and your doctor. As our “partner in health,” we ask you to help us in the following ways: Schedule Visits with Dr. Doan for Recommended Yearly Eye Exams, Glaucoma/Diabetic/Hypertensive/High Risk Medication Screenings and other Recommended Eye Screenings

I understand that Dr. Doan will explain to me which regular eye screenings are appropriate for my age, gender, and personal and family history. I understand I will need to complete these recommended health screenings (diabetic eye exam, glaucoma/cataract/macular degeneration screening, high risk medication screening, etc). These screenings are tests/exams that can help detect vision threatening diseases and conditions. If I visit my doctor only for treatment of immediate problems and forget to arrange for regular ophthalmologic screenings, I put myself at risk of letting serious eye problems go undetected. I will schedule regular visits with my doctor to complete my yearly ophthalmologic eye exams.

Keep Follow-up Appointments and Reschedule Missed Appointments
I understand that my doctor will want to know about how my condition progresses after I leave the office. Returning to my doctor on time gives him or her the chance to check my condition and my response to treatment. During a follow-up appointment, my doctor might order tests, refer me to a specialist, prescribe medication, or even discover and treat a serious eye condition. If I miss an appointment and don’t reschedule, I run the risk that my physician will not be able to detect and treat a serious eye condition. I will make every effort to reschedule missed appointments as soon as possible.

Call the Office When I Do Not Hear the Results of Tests
I understand that my physician’s goal is to report test results to me as soon as possible. However, if I do not hear from my physician’s office within the time specified, I will call the office for my test results.

Inform My Doctor if I Decide NOT to Follow Her Recommended Treatment Plan
I understand that after examining me, my Dr. Doan may make certain recommendations based on what she feels if the best for the health of my eyes. This might include prescribing medication, referring me to specialist, ordering tests or even asking me to return to the office within a certain period of time. I understand that not following my treatment plan can have serious negative effects on my eyes. I will let Dr. Doan know whenever I decide not to follow her recommendations so that she may fully inform me of any risks associated with my decision to delay or refuse treatment. Thank you for your partnership. As our patient, you have the right to be informed about your health care. We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have. If you need more information about your eye condition, please ask or visit our website at www.kimdoanmd.com
Patient Signature *

Clear
Date *

Month Day Year
Date
PATIENT INFORMATION
Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Birth Date *

Month Day Year
Date
Age *
Sex *

M F
Phone Number *

Area Code Phone Number
Marital Status *

Married Single Widowed Divorced
Race *

American Indian White or Caucasian Asian Black/African American Pacific Islander Latino or Hispanic
Language Preference *

English Spanish Vietnamese Chinese Other
Email *
example@example.com
Driver's License *
Social Security # *
Employer Name
Occupation
Work Phone

Area Code Phone Number
Business Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Spouse Details
Name

First Name Last Name
Phone Number

Area Code Phone Number
Occupation
Business Name
Business Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Referred by:

Friend Relative Doctor
PERSONAL INSURANCE INFORMATION

Must complete for Billing
Primary Insurance Co. *
Subscriber *
Name of nearest relative/friend not living with you (for medical emergency) *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Group Number *
Certificate Number *
AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS
I hereby authorize Kim T. Doan, M.D. to furnish information to insurance carriers on my behalf concerning my illness, and I hereby irrevocably assign to the doctor all payments for medical services rendered. I understand that I am financially responsible for all charges not covered by my insurance benefits. A photocopy of this assignment is as valid as the original.
Patient Signature *

Clear
Date *

Month Day Year
Date
PATIENT RIGHTS AND RESPONSIBILITIES
Patient Rights
- The Right to be treated with respect and dignity.
- The Right to make treatment choices.
- The Right to refuse treatment.
- The Right to obtain medical records.
- The Right to informed consent in language understood.
- The Right to make decisions about end- of-life care.
- The Right to exercise these rights without regard to sex, economic status, educational background, race, color, religion, ancestry, national origin, sexual orientation or marital status or the source of payment for care.
Patient Responsibilities
- Maintain healthy habit
- Be respectful to provider
- Be honest to provider
- Comply with treatment plan
- Make decisions responsibly
- Understand prescription drugs and possible side effects
- Meet financial obligations
- Avoid putting others at risk
Patient Signature *

Clear
Date *

Month Day Year
Date
ELIGIBILITY WAIVER
Patient Name *

First Name Last Name
Health Plan *
ID Number *
Effective Date *

Month Day Year
Date
Physician Name: Kim T. Doan, M.D.
The Patient or Patient’s Legal Representative hereby certifies that he/she is eligible for health plan benefits coverage, and has chosen the above stated physician as the provider of his/her health care.

Furthermore, the Patient/Patient’s Legal Representative understands that if he/she is found ineligible for coverage of plan benefits, he/she is financially responsible for all costs incurred during the delivery of health services, and agrees to pay these charges to the physician accordingly.
Signature of Patient/Guardian *

Clear
Date *

Month Day Year
Date
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that I received a copy of this medical practice’s Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I will be offered a copy of any amended Notice of Privacy Practices at each appointment.
*

I would like to receive a copy of any amended Notice of Privacy Practices (this is available on our website www.kimdoanmd.com)
Printed Name *

First Name Last Name
Telephone *

Area Code Phone Number
Date *

Month Day Year
Date
Signature *

Clear
If not signed by patient, please indicate:
Relationship

Parent or guardian of minor patient Guardian or conservator of incompetent patient Beneficiary or personal representative of deceased patient
Patient Name

First Name Last Name
REVIEW OF SYSTEMS

Do you currently have any of the following problems?
Please list ALL medications you are taking, including eye drops. *
Please indicate with "None" if not applicable.
Are you currently taking any medications *

Yes No
Do you have any allergies to any medication? *

Yes No
Constitutional *

Fever Weight Loss Other None
Eyes *

Glaucoma Cataract Lazy eye Retina problems Other None
Previous eye/lasers/surgery/injury? *

Yes No
Please specify
Ear/nose/mouth/throat *

Hearing loss Sinus problems Sore throat None
Cardiovascular *

Heart problems Chest pain Irregular heartbeat Hypertension None
Respiratory *

Asthma Shortness of breath Wheezing Coughing None
Gastrointestinal *

Heartburn Abdominal pain Diarrhea Vomiting None
Genitourinary *

Urinary problems Blood in urine None
Integumentary *

Skin rashes Excessive dryness None
Musculoskeletal *

Muscle aches Joint pain Swollen joints None
Neurological *

Numbness Weakness Headaches Paralysis None
Hematologic/Lymphatic *

Blood disorders Leukemia None
Allergic/Immunologic *

Hay fever Allergies None
Endocrine *

Thyroid problems Diabetes Elevated cholesterol/lipids None
Psychiatric *

Depression Anxiety None
Family history
Do any eye diseases run in your family? (check all that apply) *

Glaucoma Macular degeneration Strabismus/Lazy eye Retinal Detachment Blindness/Loss of vision None
Social history
Last Eye Exam *

Month Day Year
Date
Dilated *

Yes No
Do you smoke? *

Yes No
How much?
Do you drink alcohol? *

Yes No
How much?
Do you wear glasses? *

Yes No
Do you wear glasses to drive? *

Yes No
Have you received an Influenza Vaccine? *

Yes No
Have you received a Pneumococcal Vaccine? *

Yes No
Any areas of concern? *

Fine lines/Wrinkles/Major lines around mouth & nose Decreased vision (distance or near) Glare/Halos/Cataracts Droopy eyelids Other None
Please specify *
Date *

Month Day Year
Date
Should be Empty:

PATIENT PARTNERSHIP PLAN

PATIENT INFORMATION

PERSONAL INSURANCE INFORMATION

AUTHORIZATION TO RELEASE INFORMATION AND ASSIGNMENT OF BENEFITS

PATIENT RIGHTS AND RESPONSIBILITIES

ELIGIBILITY WAIVER

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

REVIEW OF SYSTEMS