Manneye.Com • 1(800)MY-VISION
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MannEye.com • 1(800)MY-VISION Medical History Questionnaire 6 9 8 - 4 7 4 6 Name: Date of Birth: Date: Height: Weight: Do you wear contacts or glasses? Yes No Type: List any medications you currently take with dosage Do you have allergies to medications? (Rx or over-the-counter): Yes No If yes, please list below. Your Pharmacy Phone#: Have you or any of your family members been diagnosed with any of the following conditions? Condition: You Family Details Glaucoma Macular Degeneration Cataracts Retinal Detachment Keratoconus Dry Eyes Please list any surgeries you’ve had: Please list any other medical conditions you may have (Diabetes, High Blood Pressure, Thyroid, etc.:) Other: AIDS, HIV+, Hepatitis, Cancer, etc.: Pregnant/Nursing? Yes No Do you drink alcohol? Yes No How often? Do you smoke? Yes No How often? Please check the box if you are having problems in any of the following areas: Allergic/Immuno Cardio Constitutional Endocrine Environmental Allergies Chest pressure or Fatigue Cold Intolerance Food Allergies discomfort Fever Heat Intolerance Seasonal Allergies Irregular Hearbeat/ Night Sweats Excessive thirst/dry mouth Palpitations Details: Details: Excessive hunger Details: ENMT GI GU Hema/Lymph Hearing loss Constipation Difficulty urinating Bleeding Details: Diarrhea Blood in urine Bruising Vomiting Excessive urination Details: Details: Details: Integumentary MS Psych Neuro Rash Joint pain Emotional Changes Dizziness Details: Joint swelling Depression Abnormal walking Muscle weakness Details: Headache Details: Details: Respiratory Chief Complaint: Please check any of these you are experiencing Environmental Allergies Blurry Vision Floaters Glare Dryness Food Allergies Decreased Vision Trouble Driving Redness Pain Seasonal Allergies Foreign Body Bloodshot Headaches/ Burning Details: Trouble Reading Halos Flashes Failed Vision Other, Please explain: Tired Eyes Screening Signature on File, Assignment of Benefits, Financial Agreement HIPAA Notice Name: Date: 1. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to The Mann Eye Institute for services furnished me by Doctor(s). I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the CMS 1500 form, my signature authorizes releasing the information to the Insurer or agency shown. The Mann Eye Institute accepts the charge determination of the Medicare carrier as the full charge, and I am responsible for the deductible, coinsurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier. 2. MEDIGAP: I understand that if a MediGap policy or other health insurance Is Indicated in Item 9 of the HCFA1500 form, my signature authorizes release of the Information to the insurer or agency shown. I request that payment of authorized secondary Insurance benefits be made on my behalf to The Mann Eye Institute, If possible or otherwise to me. 3. OTHER INSURANCE: I authorize payment of my medical and surgical Insurance benefits to The Mann Eye Institute. I understand I am financially responsible for any charges whether or not paid by said Insurance. If co-payments and/or deductibles are designated by my Insurance company or health plan, I agree to pay them to The Mann Eye Institute. I authorize The Mann Eye Institute to release any Information required to process any and all claims for reimbursement on my behalf. A copy of this authorization may be used in place of the original. 4. NON-COVERED SERVICES: I understand that The Mann Eye Institute’s contract with health care services plans (i.e., HMOs, PPOs) relates only to items and services which are “covered” by the health care service plans. Accordingly, I accept full financial responsibility for all Items or services, which are determined by the health care service plans not to be covered, including the refraction fee. I agree to cooperate with The Mann Eye Institute to obtain necessary health care service plan authorizations. 5. FINANCIAL AGREEMENT: I agree that in return for the services provided to me by The Mann Eye Institute, I will pay my account at the time service is rendered. If my account is sent to an agency for collection, I agree to pay collection expenses and reasonable attorney's fees as established by the court and not by a jury in any court action. I understand and agree that If my account Is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance are hereby assigned to The Mann Eye Institute. If co-payments and/or deductibles are designated by my Insurance company or health plan, I agree to pay them to The Mann Eye Institute. However, I understand that I am primarily responsible for the payment of my bill. 6. HIPAA NOTICE OF PRIVACY PRACTICES: I acknowledge that I have received the Notice of Privacy Practices Issued by The Mann Eye Institute that was effective April 14, 2003. I agree th to allow electronic communication as defined in security practices effective March 26th , 2013. Please direct complaints to: Texas Department of State Health Services 110 West 49th Street, Austin, TX. 78756 Phone: 1.888.973.0022 I have read and understand these instructions and have a copy for my review. Signature Demographics Date: Date of Birth: Patient's Name: Last First MI Address: Street City State Zip Patient SSN# Sex: M F E-mail: Preferred Phone: Alternate Phone: Policy Holder Information: What Insurance Will We Be Filing? Policy Holder Name: DOB: SSN# Relationship to Patient: Occupation: Employer: Certain races or ethnicities have an increased risk for different conditions so we ask you please complete the following: ETHNICITY: Latino Non-Latino Unknown/Decline Language Preference: Check the applicable RACE below: American Indian / Alaskan Native Native Hawaiian / Pacific Islander White Asian Black / African American Other Race Unknown / Decline How did you hear about us? (Please Be Specific) ________________________________________ Referring Eye Doctor/Physician: Phone # Last Exam: In case of emergency, please contact Phone # I hereby consent to a health examination, related diagnostic procedures and treatments provided by Mann Eye Institute. I also authorize the use of my photographs or data collections taken to document my ocular condition for routine care or use in research and professional publication. Photo static copies of this authorization will be considered valid as the original. By signing below, I authorize the following people to receive information regarding my treatment or care. (If you wish to add names later on, please confirm this in writing, or contact our staff.) Spouse: yes no Parent: yes no Other: yes no Signature: Printed Name: (Please circle one) Patient Legal Guardian MEI – 004d (1/17) HOW DID YOU HEAR ABOUT US? At Mann Eye, we want to make sure we spread the word about vision care effectively. Please let us know how you heard about us. Check all that apply. Thank you for your input. NAME: EMAIL: PHONE NUMBER: Radio TV Online KUHF - 88.7 “NPR” KHOU CBS-11 Yelp KKBQ - 92.9 “The New 93Q” KRIV FOX-26 Google Search KTHT - 97.1 “Country Legends” Cable TV (Channel: ) Bing Search KTBZ - 94.5 “The Buzz” TV on Mobile App Yahoo Search KILT - 100.3 “The Bull” Facebook KRBE - 104.1 "Top 40" Other Twitter Other Optometrist/Physician Referral Instagram Friend/Family Referral Snapchat Print Drove By YouTube Houston Chronicle Healthgrades Other Groupon Ad on a Website: (Where: ) We offer various services here at Mann Eye. Would you or a family member be interested in learning more about the following? NAME: EMAIL: PHONE NUMBER: Check all that apply. LASIK Multifocal Lenses Eliminate Reading Glasses (Active Life Lens Procedure) (Corneal Inlay Procedure) Dry Eye Treatments Cataract Surgery Cosmetic Services Glaucoma Treatment (BOTOX/Juvéderm/ThermiEyes) CONTACT LENS EVALUATION & FITTING AGREEMENT A Contact Lens Evaluation & Fitting must be performed annually for ALL CONTACT LENS WEARERS. It is necessary to renew your current contact lens prescription and is in addition to the comprehensive eye examination fee. Patients require extra time and testing beyond what is covered in a routine eye exam. The Contact Lens Evaluation Fee will range in price depending on the complexity of contact lenses worn: TYPE OF FITTING PATIENT FEE PATIENT LENS TYPE $45 Monitor No changes Follow Up Visits NOT Included Basic Fitting - L1 $120 Soft Spherical, Soft Toric Advanced Fitting - L2 $195 Monovision, Multifocal, RGP Keratoconus/Irregular Astigmatism Medical Fitting - L3 $350 Hybrids and Non-Scleral RGP’s $500 Complex Medical Fitting - L4 Scleral $350 (Refit) A Contact Lens Evaluation and Fitting process includes: Professional examination and determination of contact lens fit and power Trial pair of contact lenses (if available) Professional insertion and removal training (if needed) Non-medical follow-up visits and necessary lens changes - required within 45 days of the date of your evaluation (excludes Monitor) The Contact Lens Evaluation and Fitting Fee is for professional services rendered, is NON-Refundable, and does NOT include the cost of the contact lenses. By signing below, I acknowledge that I have read and understand this agreement. I have also had the opportunity to ask questions about the agreement and services provided. _____________________________________________________ PRINT PATIENT NAME _____________________________________________________ _________________ SIGNATURE OF RESPONSIBLE PARTY DATE REFRACTION POLICY The refraction is a critical part of any eye examination and is not just for an eye glass prescription. It helps us determine whether one’s vision is reduced by an eye disease or the progression of an eye disease such as cataract, macular degeneration, etc. The fee for refraction is collected at the time of service and is in addition to any co-payment or deductible required by your insurance company.