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Moda EyeCare Patient Registration Form
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2017-11-30T19:10:37+00:00
Moda EyeCare Patient Registration Form
Patient Information
Name
*
First
Middle
Last
Today's Date
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Cell Phone
Birth Date
*
MM slash DD slash YYYY
Social Security Number
XXX-XX-XXXX
Sex
Male
Female
Email
Last Medical Exam
Last Vision Exam
Preferred Method of Contact for Appointment Reminders
Cell
Home
Email
Text
Medical Doctor's Name
Previous Eye Dr.
Marital Status
Spouse's Name
Occupation
Work Status
Full Time
Part Time
Retired
Student
Employer
Work Phone
Vision Insurance
Primary Medical Insurance
How did you hear about our office?
Insurance website
Google
Yahoo
Walk By
Yellow Pages
Referral
If "Referral", who may we thank for referring you?
Insured Party Information
If self, continue to next section
Insured Name
First
Middle
Last
Relationship to Patient
Insured Address (If different from above)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Insured Birth Date
MM slash DD slash YYYY
Employer
Work Phone
Medical History
List any medications you take (including oral contraceptives, aspirin, over the counter medications and vitamins):
Do you have any environmental allergies or allergies to medications?
Yes
No
If yes, please explain:
List all major injuries, sugeries and/or hospitalizations
Check any of the following that you have had
Crossed Eyes
Lazy Eye
Drooping Eyelid
Glaucoma
Retinal Disease
Cataracts
Eye Infection
Eye Injury
Do you wear glasses?
Yes
No
If "yes", hold old is your present pair?
Do you wear contacts?
Yes
No
If "yes", what type do you wear?
Family History
Please note any family history (parents, grandparents, siblings, children) for the following conditions:
Blindness
Cataracts
Crossed Eyes
Glaucoma
Macular Degeneration
Retinal Detachment/Disease
Cancer
Diabetes
Heart Disease
High Blood Pressure
Autoimmune Disease
Thyroid Disease
Other
If "other", please explain
If you marked any of the above, please list the relationship to you
Social History
Do you drive?
Yes
No
If "yes", do you have a visual difficulty when driving?
Yes
No
If "yes", please describe
Do you use tobacco products?
Yes
No
If "yes", what type? Amount? How many years?
Do you drink alcohol?
Yes
No
If "yes", what type? Amount? How many years?
Do you use illegal drugs?
Yes
No
If "yes", what type? Amount? How many years?
Review of Systems
Do you currently or have any problems in the following areas?
Fever
Weight Loss/Gain
Integumentary (Skin) problems
Headaches
Migraines
Seizures
Loss of Vision
Blurred Vision
Distorted Vision/Halos
Loss of Side Vision
Double Vision
Eye Dryness
Eye Mucous Discharge
Eye Redness
Eyes Sandy or Gritty Feeling
Eyes Itching
Eyes Burning
Foreign Body Sensation
Excess Tearing/Watering
Glare/Light Sensitivity
Eye Pain/Sorness
Chronic Infection of Eye or Lid
Chronic Stye/Chalazion
Flashes/Floaters in Vision
Tired Eyes
Thyroid Dysfunction
Other Glad Dysfunction
Allergies/Hay Fever
Sinus Congestion
Runny Nose
Post Nasal Drip
Chronic Cough
Dry Throat/Mouth
Asthma
Chronic Bronchitis
Emphysema
Diabetes
Heart Pain
High Blood Pressure
Vascular Disease
Diarrhea
Constipation
Kidney/Bladder Problems
Rheumatoid Arthritis
Osteoarthritis
Muscle/Joint Pain
Anemia
Bleeding Problems
Allergic/Immunologic
Psychiatric
If you answered "yes" to any of the above or have a condition not listed, please explain:
Notice of Patient Privacy Rights, Protection, and Responsibilities
Servies Provided Without Referral Authorization
As a member of a vision care program, I acknowledge for today's visit that I will assume full financial responsibility for services rendered to me if my vision insurance carrier denies or does not cover my claim for these services.
Medical Necessity
If my insurance determines that a medical service and/or material are not covered, I acknowledge that I have been notified and will assume full responsibility for the service(s) and/or material stated below.
Copay's
I understand that I am responsible to pay all co-payments at the time of service, prior to leaving. Co-payments cannot be waived at any time by the provider of service or Moda EyeCare.
Deductibles
If my insurance determines that I have not met my deductible, I understand that I will be fully responsible for payment in a timely manner, no more than 30 days after I have been notified by insurance and/or provider. Yearly deductibles cannot be waived at any time by Moda EyeCare.
Professional Services and Materials
I understand that I am responsible for 100% of all professional fees rendered on the date of service. I understand that I am also required to make payment for at least 50% of materials at the time materials are ordered. If I am supplying my own frame, I understand that many plastic and metal products may weaken over time and I will not hold Moda EyeCare or my insurance carrier responsible for accidental laboratory breakage. If I do not pick up my materials within 60 days from my initial order, my materials will be returned to the laboratory, and my initial deposit will not be refunded. If I am to receive contact lenses by mail, I understand that I am required to pay in full at time of service. Our Patient Satisfaction Guarantee applies to single vision and progressive lenses. We use only premium single vision optics and premium progressive addition lenses, otherwise known as no line bifocals. Less than one percent of our patients have difficulty adapting to our premium progressive lenses. We will make a non-adapt progressive lens or single vision lenses one time, in the same frame. If it is still unsatisfactory, we will replace it with a lined bifocal or a single vision lens, in the same frame. While we make every attempt to solve these rare issues, no refunds will be given in a case where a patient does not adapt to a progressive lens or single vision lens.
HIPAA
I understand that under the Health Insurance Probability ACT of 1996 (HIPAA), which I have been provided a copy, that I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly, obtain payment from third party payers, and conduct normal healthcare operation such as quality assessments and physician certifications.
Date
MM slash DD slash YYYY
Signature
Name
First
Middle
Last
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