Dr. Michael D. Herrera

Date

SS#

Date of Birth

Age

Name

Last MI First

Address

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

Home Phone

Work Phone

Cell Phone

Your Email

Sex

Male
Female

Marital Status

Single
Married
Widowed/Other

Employer

Occupation

Emergency Contact

Emergency Contact Phone Number

Emergency Contact Relationship

Primary Care Physician

Primary Care Physician Phone

Address

Street Address City State / Province / Region

*VISION PLAN BENEFITS COVER “ROUTINE VISION” EXAMS. ANY MEDICAL HISTORY OR DIAGNOSIS THAT CAN AFFECT THE EYES WILL RESULT IN THE VISIT BEING BILLED TO YOUR MEDICAL INSURANCE AND MAY REQUIRE ADDITIONAL COPAY.*

Do you have a Vision Plan?

Yes
No

Company

ID#

Members Name

DOB

Do you have a Medical Plan?

Yes
No

Company

ID#

Members Name

DOB

Do you or any of your family have any problems with any of the following? (Check all that apply.)

Diabetes - Relation

Cataract - Relation

Glaucoma - Relation

Macular Degeneration - Relation

High Blood Pressure - Relation

Retinal Detachment - Relation

Mental - Relation

Endocrine - Relation

Respiratory - Relation

Gastrointestinal - Relation

Ears/Nose/Throat - Relation

Cardiovascular - Relation

Nervous - Relation

Genitourinary - Relation

Musculoskeletal - Relation

Blood Problems - Relation

Skin Problems - Relation

Eye Problems - Relation

Allergies - Please List

Allergies - Effects

List Current Medications and Dosage

List your current weight

List your current height

Do you use Cigarettes/tobacco?

Yes
No

Alcohol?

Yes
No

Other Substance (s)

Yes
No

List other Substances

Have you had any eye operations?

Yes
No

List Operation

Date of Operation

Have you had an eye injury?

Yes
No

List Injury

Date of Injury

Do you have dry eye?

Yes
No

Do you wear glasses?

Yes
No

Do you wear contact lenses?

Yes
No

*IF YOU ARE A CONTACT LENS WEARER ADDITIONAL FEES ARE CHARGED FOR CONTACT LENS SERVICES. IF YOU HAVE ANY QUESTIONS REGARDING CONTACT LENS FEES, PLEASE ASK PRIOR TO YOUR EXAMINATION.*

Responsible Party Signature

Date

I, the undersigned, assign all insurance or Medicare benefits, to Dr. Michael D. Herrera for any services furnished to me. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize any holder of medical information about me, to release such information to my insurance or the Health Care Financing Administration and its agents to determine the benefits payable for related services. I understand my signature requests that payments be made and authorizes release of medical information necessary to pay the claim. In the event of default in any amounts due, and if this account is placed in the hands of a collection agency, attorney for collections or legal action, I am to pay an additional charge equal to the cost of collection including collection agency, bank returned items charges, attorney fees and court cost incurred. In Insurance or Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the insurer or Medicare carrier as the full charge, and the patient is responsible for only the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the charge determination or the insurer or Medicare carrier.

Signature of Beneficiary

YOUR INSURANCE OR MEDICARE MAY NOT PAY FOR ALL CHARGES, EVEN SOME CARE THAT YOU OR YOUR HEALTH CARE PROVIDER THINK IS MEDICALLY NECESSARY. I UNDERSTAND THAT MEDICARE WILL NOT PAY FOR THE PORTION OF MY EXAM THAT DETERMINES MY VISION CORRECTION AND I AM RESPONSIBLE FOR $35.00 PLUS TAX FOR THIS SERVICE. FURTHER, I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY MEDICAL CHARGES INCURRED DURING MY VISION EXAM, AND THESE SERVICES WILL BE PERFORMED BASED ON THE DOCTOR’S PROFESSIONAL DISCRETION.

Your signature below indicates that you have read and understood the HIPPA notice regarding the uses and disclosures of your protected health information - http://goo.gl/a9u1Zn

*Your Signature above indicates that this information has been made available to you*