Accent EyeCare New Patient

Name

First Last

Sex

Male
Female

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone

Work Phone

Cell Phone

Occupation/Employer

Race

1st Language

Insurance Information

Plan Name

Employer

Group

Insured Name

First Last

Primary Insured Date of Birth

Relationship to Patient

Insured Identification Number

Patient SS#

If used as your ID by Insurance Co.

Medical History

Reason for todays visit

Date of last eye exam?

How did you hear of us?

Name Eye Doctor

Name Medical Doctor

Last Medical Exam

Insured Identification Number

Insured Group Number

Date

Eye & Health History

Do you or have you worn glasses?

No
Yes-Full Time
Yes-Distance
Yes-Reading

Have you worn contact lenses?

If yes, Which BRAND?

Have you had eye surgery, injury, or infection?

If yes, Describe

Do you have frequent headaches, double vision, or sensitivity to bright light?

Do you see Flashes or light, floaters, vision loss?

Select all that apply

If you selected any of the above, please explain:

List all Medications

List any Allergies

TO OUR PATIENTS

Our mission is to provide the highest level of care for your eyes. To achieve this goal, our doctors will recommend at least one of these test to all of our patients yearly.

DIGITAL RETINAL IMAGING

• Procedure: Retinal imaging is the best way to keep an accurate record of your inner eye health. • When to do this test: lf you have no risk factors for eye disease our doctors recommend images be taken at your first eye examination and then every 1-2 years thereafter. If you have risk factors for eye disease or are over 40 years old, we recommend taking retinal photos yearly to monitor any changes to your retina (glaucoma, macular degeneration, retinal thinning/detachments, melanoma, etc.) • Benefits of Digital Retinal lmaging: Early detection and treatment of eye problems and disease. • Side effects of Digital Retinal Imaging: NONE. • Fee: Digital Retinal Imaging is covered by many, but not afí insurances. Please inquire at front desk if you are unsure if your insurance covers this procedure. If not covered, the fee is $39.00

Please Select One

I accept Retinal Imaging
I Decline

DILATION OF THE PUPILS (DFE: DILATED FUNDUSCOPIC EXAMINATION)

• Procedure: Dilation eye drops are placed into each eye to enlarge the pupil size for examination. • Benefits of a Dilated Eye Exam: Early detection and treatment of eye problems and disease. • Side effects of Dilation: Increased sensitivity to sunlight and blurry near vision for up to 5 hours on average. Most patients have no problem with distance vision and driving. Disposable sunglasses are provided for you. • Fee: Dilation is covered by many, but not alt insurances. Please inquire at front desk if you are unsure if your insurance covers this procedure. If not covered, the fee is $25.00

Please Select One

I accept Dilation
I Decline

*** For most patients with low risk of eye disease RETINAL IMAGING can be done in place of dilation.

*** For most patients, one of the above test per year is sufficient. Some eye conditions such as diabetic eye disease may require both test

Signature of Patient or Parent/Legal Guardian

I have read and understand the information provided above. If declining the above tests, I understand that I am not allowing the physicians to conduct the most thorough examination of the eyes. This will decrease the ability to detect eye disease such as retinal detachments, glaucoma, etc.

Date

AUTHORIZATION AND ASSIGNMENT

Signature of Patient or Parent/Legal Guardian

I authorize Accent Eyecare to take any and all actions necessary to obtain payment from my insurance company, the Social Security Administration or other responsible party for any and all services provided to me by the doctor and staff of Accent Eyecare. Further, I assign any and all payments due from my insurance company, the Social Security Administration or other responsible party directly to this office. I realize that in the event that my insurance company or other responsible party erroneously sends payments owed to Accent Eyecare directly to me, those payments legally belong to Accent Eyecare. I realize that I must forward those payments immediately to Accent Eyecare. I understand that my signature below allows Accent Eyecare to release my confidential medical record to the insurance company, The Social Security Administration or other responsible party, in order to expedite payment of my claims. I further understand that any co-pays or deductible amounts not paid by my insurance company, The Social Security Administration, or other responsible parties, do become my responsibility. In addition, I understand that I am fully responsible for any costs associated with that collection process. I further understand that if after my claim has been submitted to my insurance company, Social Security Administration, or other responsible party, and it is then determined that I am not eligible; I am responsible for immediately paying the complete balance due. This authorization is effective for all appointments at Accent Eyecare.

HIPPA PRIVACY POLICY

Signature of Patient/Guardian

By signing this acknowledgment of Receipt of Notice of Privacy Practices, I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that Accent Eyecare may use and disclose necessary personal health information to another party to permit us to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by Accent Eyecare (for example, mailings of exam reminders or information about services/products provided by Accent Eyecare). I can be assured that Accent Eyecare does not sell my personal health information to a third party ïoz said party’s own use. I acknowledge and agree that Accent Eyecare may submit my vision benefit claims to my health plan to receive reimbursement directly for the vision services and products that I have received.

Date