4081 Superior Vision Registration

4081 Superior Vision Registration Form

Welcome to Superior Vision
Today's Date
MM slash DD slash YYYY
Name
First Middle Initial Last
Home Phone
Cell Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SSN
Age
Date of Birth
MM slash DD slash YYYY
Sex
- Male
- Female
Marital Status
- Single
- Married
- Divorced
- Widowed
- Other
Race
Occupation
Email
Would you like to receive TEXT message confirmations?
- Yes
- No
How did you hear about us?
What is the name and number ofyour Primary Care Physician?
Guardian
Primarv lnsurance: Please Select (Vision or Medicall
- Vision
- Medical
Subscriber's Name
SSN
DOB
MM slash DD slash YYYY
Relationship to Patient
Phone
Address (if different from patient)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company
ID#
Group#
Pharmacy Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Questions
What's the main reason for your visit today?
- Exam
- Glasses
- Contacts
Have you worn?
- Eyeglasses
- Contacts
Have you ever had LASIK?
- Yes
- No
If yes, when:
When was your last eye exam?
Do you smoke?
- Yes
- No
How long?
How many packs a day?
Do you have allergies?
- Yes
- No
Seasonal?
- Yes
- No
- Other
EYE AND GENERAL HEALTH HISTORY
Please select all that apply
- Asthma, Bronchitis, Emphysema
- Kidney Disease
- Tuberculosis
- Diabetes
- lnsulin
- Migraines
- Psychiatric Disorder
- Any Nervous Disorder
- Heart Attack or Heart Failure
- Chest Pain
- Congestive Heart Failure
- Ulcer, Heartburn
- Thyroid Disorder
- Sickle Cell Anemia
- Head or Spinal lnjuries
- Seizures, Convulsions, Fainting
- Stroke
- Permanent Defect from lllness, Disease, or lnjury
- Pregnant
- High Blood Pressure
- HlV/AIDs
- Suffering from other Disease
- Other Diagnosed Health Problems
- Arthritis
- Cancer
- Lymphoma
If diabetes, # of years
If insulin, # of years
If cancer, type:
Please check all surgeries vou have had:
- Tonsillectomy
- Heart By-Pass
- Hysterectomy
- C-section
- Stint
- Gall Bladder
- Knee
- Hip
- Mastectomy
- Appendectomy
- Mole Removal
- Plastic Surgery
- Endoscopy
- Back
- Transplant
- Dental Surgery
- Hernia Repair
Other surgeries (Please list)
Dates of surgeries
Please list all medications you are currently taking:
Please List Medications you are ALLERGIC to:
Ocular History (Have you been diagnosed with any of the following in the Past?l
- Cataracts
- Retina Disease
- Glaucoma
- Crossed Eyes
- lritis (red inflamed eye)
- Cornea Disease(front surface of Eye)
- Injury
- Other Eye Disorder
Cataracts (Date of Surgery) Right Eye
Cataracts (Date of Surgery) Left Eye
Do you have a lens implant?
- Yes
- No
Retina Surgery (Date of Surgery) Right Eye
Retina Surgery (Date of Surgery) Left Eye
Explanation of Eye lnjury
Family History (Blood Relatives only: Mark Relation, i.e. Mother, Father, Grandparent' Aunt)
Glaucoma
Cataracts
Cornea Disease
Macular Degeneration
Retinitis Pigmentosa
Blindness
Cancer
Diabetes IDDM/TYPE ll
Heart Attack
Diabetic Retinopathy
Retinal Detachment
Stroke
Tuberculosis
High Blood Pressure
Other General Medical Problems:
Loss of vision
- Yes
- No
Floaters
- Yes
- No
Eye pain
- Yes
- No
Burning
- Yes
- No
Blurred or Distorted Vision
- Yes
- No
Flashes of Light
- Yes
- No
Loss of Side Vision
- Yes
- No
Glare/ Sensitivity to light
- Yes
- No
Do you have problems with night vision?
- Yes
- No
Financial Policy
A clear understanding of our Financial Policy is an important part of our professional relationship. We are pleased to discuss the financial aspects of your care. Feel free to ask questions regarding your fees, financial responsibilities, insurance coverage, or the Financial Policy. All patients must complete the "New Patient" forms before seeing the Doctor. The following forms of payment are accepted: Cash, Personal Checks, Debit Cards, Care Credit, Health Savings Cards, VISA, MASTERCARD, AMERICAN EXPRESS, and DISCOVER.
INSURANCE
Each insurance plan is different and it is YOUR responsibility to check with your insurance company regarding coverage prior to your appointment. Please remember too that we file the insurance as a courtesy for you, and we will attempt to collect on all claims. Failure to pay by the insurance company for any reason will result in the bill becoming your responsibility. Insurance is a contract between you and your insurance company. Our office will NOT become involved in disputes between you and your insurance regarding deductibles, co-payments, covered charges, or secondary insurance other than to provide information regarding the services provided by our practice. We will file with most insurances: however, we are not contracted with SPECTERA at this time. When a doctor contracts with an insurance company, the doctor is considered "in network". The insurance company has specific payment schedules for both "in network" and "out of network" providers. For example, a plan that pays 80% for an "in network" provider may only cover 60% for an "out of network" provider. You will be responsible for the portion that is not covered by your insurance.
MEDICAID
We do cunently accept Medicaid. providing that you are eligible for that date of service. If you are NOT eligible, the charges for that day will be your responsibility and you will be required to pay the bill. Sometimes, the Medicaid eligibility slip shows that the patient has a primary insurance. Medicaid is always regarded as secondary insurance and will NOT pay until the insurances outlines on the slip have been billed. We understand that sometimes theses primary insurances are outdated, but we have no choice but to file with them. You are responsible for providing us with this primary insurance information. If you care to dispute the insurances, you will need to contact your caseworker.
RELEASE OF OPTICAL INFORMATION
Signature
I hereby give permission to release my optical information (for purpose of collection of my optical bill) by means of electronic submission, mail, far, or phone I hereby give permission to contact me via phone, answering machine, and/postcard to remind me of my optical appointments or need for optical re-care
PAST DUE ACCOUNTS
If it becomes necessary for our office to use a collection agency or legal representation to collect a seriously past due account, you will be liable for any fees incurred during the collection process. If you have any questions or concerns, please let us know.
Patient Name
First Last
Responsible Party
Responsible Party Signature
I have read and understand the financial policy and agree to the terms as stated above.
Retinal images are an essential part of your annual comprehensive eye exam.
Optomap: When reviewed, the scan becomes a permanent part of your medical record, enabling the doctor to make an important comparison should potential vision-threatening conditions show themselves at a future examination. Retinal problems such as macular degeneration, glaucoma, retinal holes, retinal detachments, diabetic retinopathy, and many systemic diseases can now be seen without dilation* for most patients. The doctors at Superior Vision highly recommend Optomap imaging for all patients on an annual basis. Optomap imaging allows the doctor to compare ocular health changes and early detection of many ocular diseases
Please check ONE of the following:
- I understand and accept the Optomap retinal imaging ($35 copay). ln MOST cases, dilation is not necessary if retinal imaging is performed.
- I prefer Dilation today (no copay): Please allot an additional 20 minutes for your examination to allow the eyedrops to become effective. Side effects of dilation include light sensitivity and blurry vision.
I have read and understand this document:
Signature
Date
MM slash DD slash YYYY

4081 Superior Vision Registration Form

Welcome to Superior Vision

Questions

EYE AND GENERAL HEALTH HISTORY

Family History (Blood Relatives only: Mark Relation, i.e. Mother, Father, Grandparent' Aunt)

Financial Policy

INSURANCE

MEDICAID

RELEASE OF OPTICAL INFORMATION

PAST DUE ACCOUNTS

Retinal images are an essential part of your annual comprehensive eye exam.

I have read and understand this document: