Gubman Eye Associates

Eye and Sight Center Patient Form

Which office will you be visiting?*

Name*

First Last

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Cell Phone*

Email*

For office only use

Health Insurance Co.*

Health Insurance Member ID #*

Subscriber/Member Name:*

Subscriber/Member Date of Birth*

Vision Plan (if applicable)*

Vision Insurance ID #*

Family Doctor*

Family Doctor's Phone

Pharmacy*

Location*

Who referred you to our office?*

(Physician/Friend/Relative/Internet/Insurance)

Patient/Guardian Responsibility*

I have read and understood the below

We learn about you and your insurance from the confidential information you provide to us. We are not agents of your employer or insurance company. If you choose to use insurance, YOU MUST PROVIDE US WITH YOUR CURRENT INSURANCE INFORMATION. REFERRALS are PATIENT RESPONSIBILITY. You are responsible for getting a referral if you need one.

My e-signature below indicates my acceptance of the following:

I agree to and understand that certain ancillary tests may be performed by trained staff and/or externs. I hereby acknowledge that Dr.Gubman and Dr. Silbert are certified Preceptors authorized by the New Jersey Dept. of Law and Public Safety.

HIPAA Notification – I have received a copy of the posted HIPAA – Notice of Privacy Practices

One Time Authorization for Signature on File – I authorize and request my health insurance company to pay directly on my behalf for any/all eligible services rendered.

I understand that I am financially responsible for all services rendered and received by me or my dependents. I am financially responsible for any DEDUCTIBLE, CO-INSURANCE, CO-PAY , NON-COVERED service as determined by my Health Insurance plan. If I FAIL TO GET A REFERRAL when my insurance plan requires one, I will pay for services received. In addition, if my insurance provider denies payment or coverage, I will pay my bill for the services and materials that I received.

Patient or Guarantor Signature*
Typing your name below constitutes as a valid signature

Date*
MM slash DD slash YYYY

Confidential Medical History

Do you suffer from any of the following?*
Near Vision Blur
Distance Vision Blur
Middle Distance Blur (Dashboard/Computer)
Double Vision
Eye Strain
Focusing Trouble
Glare
Dry Eyes
Watery Eyes
Itching/Burning
Pain in/around eyes
Seeing Flashes
Seeing Spots/Lines
Headaches
None of the above

Level of Satisfaction with current Glasses*

Do you desire new glasses?*

Do You or Anyone in your Family have...?*
Glaucoma
Macular Degeneration
Cataracts
Lazy Eye or Eye Turn
Retinal Detachment
Blindness
None of the above

Other

What is your Occupation?*
Be specific so we understand your visual demands

Describe Sports/Hobbies/Special Visual Needs*

Date of last general physical examination*
MM slash DD slash YYYY

Do you have or have you suffered from:*
High Cholesterol
High Blood Pressure
Heart Attack
Asthma / Emphysema
Sinus Problems
Irritable Bowel Disease
Arthritis
Acne / Eczema
Diabetes
Thyroid Disease
Allergies
Liver Disease
Kidney Failure
Seizures / MS
Shingles / Herpes
Lupus
Infections
HIV / AIDs
None of the above

Describe any Tobacco, Alcohol or Drug Use*

Have you ever had a blood transfusion?*

Have you ever had an STD?*

Are you PREGNANT or think you could be pregnant?*

List ANY condition you have not mentioned above*

If none, please type 'none' in the field above.

List current Medications*

If none, please type 'none' in the field above.

List ANY Drug Allergies*

If none, please type 'none' in the field above.

I would like to know more about treatment options in the following areas
Dry Eye Treatment
Laser Vision Correction
Non-Surgical Vision Correction

SCANNING RETINAL IMAGER: COMPREHENSIVE AND THOROUGH EYE EXAM WITHOUT DILATING DROPS*
I have read and understood the below
Our Scanning Reginal Imager uses low level red and green light to digitally map your retina without dilating eye drops and bright lights. The digital map can be viewed on a computer monitor and will be shown to you during your visit with the doctor. 92% of patients choose the retinal scan!
DESIGNED TO DETECT: Macular Degeneration, Diabetic Retinopathy, High Blood Pressure, Hypertensive Retinopathy, Retinal Freckles (Nevi), Diabetes, Retinal Scars, Retinal Detachment/Tears, Some types of Cancer, Retinal Bleeding and Nearsighted Retinal Thinning.

BENEFITS TO EACH PATIENT: Complete Retinal examination. No dilating drops. Eye Disease Detection. No waiting for drops to work (20-30 min). Systemic Disease Detection. No Blurred vision for 4-6 hours. Better Medical documentation (digital image). No light/sun sensitivity for 4-6 hrs. Return to work/school with normal vision. No driving glare for 4-6 hrs.

The additional fee for the Retinal Imager is only $39 (It is NOT covered by insurance or vision plans).

Please choose the Retinal Imager or Dilating Drops*

I elect the Scanning Retinal Imager

I request Dilating Eye Drops and Decline the Retinal Imager

Signature*
Typing your name below constitutes as a valid signature

Do you need a CONTACT LENS evaluation?*
I have read and understood the below
Contact Lenses are prescription medical devices and require periodic medical evaluation like any other medication. Dr. Gubman and Dr. Silbert recommend at least annual visits not only to assess your vision, but more importantly, the health of your eye. Contact Lenses can and do cause complications in some patients which may not cause symptoms or complaints. These may include but are not limited to vascularization, edema and inflammation.

A Contact Lens Evaluation is necessary if you need a renewal of your Contact Lens Rx for ordering replacement lenses. Wear or bring your Contact Lenses to your Appointment.

An Examination for contact lenses is NOT part of a regular eye examination. There is a separate fee for contact lens evaluations (usually ranging from $69-$139 depending on complexity).

Do you need a contact lens examination?*

I am a Contact Lens patient and REQUEST a contact lens examination, and I will WEAR or BRING my contact lenses to my appointment.

I am a Contact Lens Patient and DECLINE a contact lens examination.

I am NOT a Contact Lens patient.

I am NOT a Contact Lens patient, but want to talk to the Doctor about alternatives to eyeglasses.

Initial to Confirm Your Choice*

Which kinds of vision correction are you interested in?*
Multifocal Contact Lenses
Astigmatism Contact Lenses
Overnight Contact Lenses
Non-Surgical Vision Correction

CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS, EXPRESS PRIOR CONSENT TO BE CONTACTED BY EMAIL AND ON WIRELESS NUMBERS*
I have read and understood the below

In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office.

We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You are free to refer to this Notice at any time before you sign this consent document. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes our submission of your health information to a billing agent or vendor for processing claims or obtaining payment; our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; our submission of your health information to auditors hired by third-party payers and insurers, among other aspects of payment described in our Notice of Privacy Practices. In order for us to service your account or to collect monies you may owe, The Eye & Sight Center, and/or our agents may contact you by telephone at any telephone number associated with your account including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to us. Methods of contact may include using pre-recorded / artificial voice messages and/or use of automatic dialing devices, as applicable. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office or from our Web site.

When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, to obtain payment for our services, and to perform health care operations. You can revoke this consent in writing at any time unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. We can decline to serve you if you elect not to sign this consent form.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or health care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

You have the option to list below, those persons with whom you authorize us to discuss your confidential information: (ie: Parents, spouse, adult children, guardian, power of attorney etc.)
Name Relationship Phone Number

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form (Specify Parent, Legal Guardian, Power of Attorney):
Relationship to Patient Print Name Source of Authority

Hidden

*
I have read and understand this consent. I consent to the use and disclosure of my health information for purposes of treatment, payment and health care operations. I consent to being contacted for payment on wireless numbers.

Signature*
Typing your name below constitutes as a valid signature

Date*
MM slash DD slash YYYY

Gubman Eye Associates, PA

Eye and Sight Center Patient Form

Confidential Medical History