Name: Patient Information Last Name: DOB: Gender: Home Phone: � ColumbiaDoctors Adult New Patient Intake Form First Name: Mobile Phone: Email: DOB: Preferred Phone: Home or Mobile (circle one) Emergency Contact: Re Iations hip: Page 1 of 4 --------------- Emergency Contact Phone: Patient Marital Status: 0 ccupat ion: Em pIoyer: Primary Care Provider (PCP): ---------------- PCP Phone: Referring Provider: Referring Phone: Preferred Pharmacy: Pharm Phone: Preferred Pharmacy Address: Please list ALL active treating physicians (i.e. pulmonologist, oncologist, internist, cardiologist, etc...) Doctor's Doctor's Name: --------------- S pecialty: -------------------- Doctor's Name: --------------- S pecialty: -------------------- Doctor's Name: --------------- S pecialty: -------------------- Doctor's Name: --------------- S pecialt y : -------------------- Collection of the following information is encouraged by federal health agencies. This information is used to monitor and improve the quality of care provided to all patients. Ethnicity: Race: o Decline Response o Decline Response o Hispanic or Latino o American-Indian or Alaska Native o Not Hispanic or Latino o Asian o Black or African American o Native Hawaiian or Pacific Islander D White D Other Preferred Language: o Decline Response Patient Financial Obligation Agreement I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible an , d make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to Columbia Doctors for services rendered. I authorize representatives of ColumbiaDoctors to release peinent medical information to my insurance company when requested or to facilitate payment of a claim. Notice of Privacy Practices: Acknowledgement of Receipt I acknowledge that I was provided with a copy of the Columbia Doctors Notice of Privacy Practices (NOPP). o Received o N/A (only if you received the notice from ColumbiaDoctors previously) Information Disclosure and Consent Columbia Doctors will provide you with the health plans that your provider(s) accepts*. If you decide to be treated by a provider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept treatment from that provider. I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information). Patient or Legal Guardian Name (Print): Patient or Legal Guardian Signature: Date: *Please refer to our website: columbiadoctors.org, for a list of insurances accepted by your provider. Version 1.9 Updated: 12/19/2017 ------------ --------------- ------------ ------------ ----------- --------- --------- ---------- ----------- ------------ ----------------- --------------- ------------------ -------------------- ------------------- ---------------------------------
Transcript
Name:
Patient Information
Last Name:
DOB:
Gender: Home Phone:
� ColumbiaDoctors Adult New Patient Intake Form
First Name:
Mobile Phone:
Email:
DOB:
Preferred Phone: Home or Mobile (circle one)
Emergency Contact: Re I at ions hip:
Page 1 of 4
---------------
Emergency Contact Phone: Patient Marital Status: 0 cc up at ion: Em p Io ye r:
Collection of the following information is encouraged by federal health agencies. This information is used to monitor and improve the quality of care provided to all patients.
Ethnicity: Race:
o Decline Response o Decline Responseo Hispanic or Latino o American-Indian or Alaska Native
o Not Hispanic or Latino o Asian
o Black or African Americano Native Hawaiian or Pacific IslanderD White D Other
Preferred Language: o Decline Response
Patient Financial Obligation Agreement I understand that all applicable copayments and deductibles are due at the time of service. I agree to be financially responsible an,d make full payment for all charges not covered by my insurance company. I authorize my insurance benefits be paid directly to Columbia Doctors for services rendered. I authorize representatives of ColumbiaDoctors to release pertinent medical information to my insurance company when requested or to facilitate payment of a claim.
Notice of Privacy Practices: Acknowledgement of Receipt I acknowledge that I was provided with a copy of the Columbia Doctors Notice of Privacy Practices (NOPP). o Received o N/A (only if you received the notice from ColumbiaDoctors previously)
Information Disclosure and ConsentColumbia Doctors will provide you with the health plans that your provider(s) accepts*. If you decide to be treated by aprovider who does not accept your health plan, you will be asked to sign a consent form agreeing that you accept
treatment from that provider.
I read and agree to all of the above (Financial Agreement, Notice of Privacy, Insurance Information).
Patient or Legal Guardian Name (Print):
Patient or Legal Guardian Signature: Date:
*Please refer to our website: columbiadoctors.org, for a list of insurances accepted by your provider.
Version 1.9 Updated: 12/19/2017
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Name: DOB: � ColumbiaDoctors Page 2 of 4
Reason for today's visit:
General Medical Questionnaire
Have you EVER had any of the following?
Asthma/Breathing Problems ........................ o Y o N Heart Disease/Disorder ............................... o Y o N
Arthritis ........................................................ o Y o N
Bleeding/Clotting Disorder ........................... o Y o N
Blood Pressure Disorder ............................... o Y o N
Blood Transfusion ........................................ o Y o N
Bowel/Stomach Problems ............................ o Y o N
Cancer .......................................................... o Y o N
Cholesterol Disorder .................................... o Y o N
Diabetes ....................................................... o Y o N
Eye Disorder (i.e. Glaucoma, cataract) ......... o Y o N
Women Only: Gynecological Issues .............. o Y o N
Lung Disorder ............................................... o Y o N
Liver Disease ................................................ o Y o N
Neurological Disorder/Chronic Headaches .. o Y o N
Psychiatric Disorder/Illness .......................... o Y o N
Pulmonary Embolism/DVT .......................... o Y o N
Stroke ........................................................... o Y o N
Seizure or Epilepsy ...................................... o Y o N
Thyroid Disorder ......................................... o Y o N
Urinary/Kidney Disorder .............................. o Y o N
Please list any other medical illnesses or problems and provide details for any of the above conditions:
Please list all past surgeries and hospitalizations and the approximate date.
Procedure/ Hospitalization Date Complications
Please indicate any major conditions/illnesses that your immediate family members have had:
Relative Condition and description Living? If deceased, at what age?
Mother oY oN
Father oY oN
Sibling oY oN
Other: oY oN
Do you currently smoke? o Y o N If no, previously? o Y o N Years smoked Packs/day
Do you use other tobacco products? o Y o N Consume alcohol? o Y o N If yes, drinks/week:
Women Only: Any past pregnancies? o Yo N How many? How many deliveries?
Version 1.9 Updated: 12/19/2017
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� ColumbiaDoctors Page 3 of 4
Please list ALL of your current medications, including over the counter medications, supplements, and herbs:
Medication Name Dose Medication Name Dose
Review of Systems
Please indicate ALL that you have experienced within the past 6 -12 months.
I, ___________________________________________________________________, give my consent to ColumbiaDoctors Ophthalmology and its employees to formally photograph me during the course of my treatment(s) in order to demonstrate my condition or disorder, subsequent therapy, and the results of such therapy. This permission includes surgical procedures when I may be sedated or anesthetized. I also give permission to photograph any tissue removed. I understand that the photographs may be used to monitor my treatment, for education, for entrance into medical societies and maintenance of membership, for professional certification, for research, for publication in journals or any other printed material and for other formats of the same (i.e. videos, online journal publication, educational discs, and so forth). My name and personal information will not be disclosed. I waive all rights and compensations for any claims for payments or royalties. I release ColumbiaDoctors and its agents, the physicians and their agents from any liability in connection with the use of such photographs.
My photographs may be used for promotional purposes (i.e. practice brochures, website, newsletters, external advertisements); I understand that at no time will my personal information and/or name be used.
You may revoke this authorization at any time by notifying ColumbiaDoctors Ophthalmology of your wishes in writing.
Revised 12/20/2017
AUTHORIZATION OF BENEFITS
Name of Beneficiary:
Health Insurance Claim#:
1 request that payment of authorized health insurance benefits, including Medicare and Medigap, be made
either to me or on my behalf to Dr. for services furnished to me by this provider.
I authorize any holder of medical information about me to release to the Health Care Financing Administration
and its agents, any information needed to determine these benefits payable for related services.
Signature of Responsible Party: Date:
Commercial Insurance
I hereby authorize direct payment of surgical/medical benefits to Dr. for services rendered
by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance
not covered by my insurance, including co-pays, deductibles, refractions, and differences between surgeon's
charges and allowable. I hereby authorize Dr. to release any medical or incidental
information that may be necessary for either medical care or in processing applications for financial benefits.
Signature of Responsible Party: Date:
Advance notice regarding Insurance Reimbursement and Beneficiary Agreement
I have been informed that refraction (the measurement of one's eyeglass prescription and the determination of
the best visual sharpness) is usually not considered by insurance companies, health maintenance
organizations, and Medicare to be medically reasonable of necessary. Knowing this, I have instructed the
doctor to proceed with the services. If insurance decides to reduce or even deny the fee or services, I agree to
pay the doctor's fee in full.
Signature of Responsible Party: ______________ Date: _____ _
Eye Glass and Contact Lens Prescription Policy
ColumbiaDoctors Ophthalmology does not accept vision insurance. You are responsible for fees of any services not covered by your medical insurance.
*A 25% fitting fee reduction if contact lens brand and prescription are not changed.
I. Refraction
A. What is a refraction?Refraction is a test done to determine the refractive error of your eyes, or the need for corrective glasses and/or contactlenses.
B. When do I have to pay for a refraction?Refraction (CPT code 92015) is a non-covered service by Medicare. As a result, your healthcare provider is required by CMS(the department to the federal government that controls Medicare) to charge for this service. Most insurance plans followMedicare's rules. All these plans consider refraction a "vision" service, and not a "medical" service.
C. How much do I have to pay?You will only be charged a refraction fee if you receive a prescription for glasses or contact lenses. Our office fee forrefraction is $80. This is collected at the time of service in addition to any co-payment your plan may require. Should yourplan pay us for the refraction, we will refund you accordingly.
D. Suggestions When Filling Your PrescriptionSince refraction is an inexact art in which errors may arise at any step, including from the patient, the doctor,and the optician making the eyeglasses, we suggest the following:
1. Fill your prescription at an establishment that will give you a warranty. At the very least, choose anoptical that agrees to make at least one adjustment at no charge to you. if you are uncomfortable with thenew prescription for whatever reason, this will enable us to make changes as necessary at no cost to you.2. Start with purchasing only one pair of new glasses with the new prescription to ensure you are happywith your vision before purchasing new pairs.3. Please address any legibility issues regarding the written prescription with the prescribing doctor priorto filling the prescription.4. Change as few parameters like lens size and shape, lens company/brand (especially with progressiveadd spectacles), as possible, with your new glasses to minimize the risk of being uncomfortable with newlyprescribed glasses.
II. Non-Medically Necessary Contact Lens Fitting
Please be aware that most medical insurance do not cover the portion of the eye examination to evaluate you for elective contact lenses. This part of the examination requires a separate evaluation in addition to the medical examination.Contact lenses are medical or cosmetic devices placed on a vital organ in your body. An improper fit may cause a host of problems including infection, permanent scarring, new growth of blood vessels, contact lens rejection and ultimately decreased vision. Based on FDA regulation, contact lens prescriptions are only valid for 1 YEAR. An annual contact lens evaluation is required.
If you are also being seen for an ocular complaint that requires a medical examination, your insurance will be billed for the medical portion.
III. What if my glasses or contact lenses don't fit well?Our physician will re-evaluate you at no charge within 60 days of your initial refraction to change yourprescription if necessary. However, our office does not pay for revision of glasses in which good faith effortswere made in measuring and writing the prescription.
I understand that refraction and contact lens examination are not included in my eye exam and there will be an additional fee. Refraction and contact lens fitting fees are non-refundable. Any changes that need to be made to your prescription must be made within 60 days of your examination. I have been fully informed and accept full responsibility to pay.
______________________________ ______________________________ ________________Patient Name Patient Signature Date
Pharmacy Information Update Form
As of Mairch 27, 2016, NYS Public Health Law requires your doctor t,o electronically prescribe (e
prescribe) all your prescription medications directly to your pharmacy. Prescriptions will no longer be
handwritten or called in to your pharmacy, except in limited circumstances. Please use this form to tell
your doctor where you want your prescriptions filled.
