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Welcome to Our Office WELCOME TO OUR OFFICE PATIENT INFORMATION INSURANCE INFORMATION Date_____________________ Vision Plan___________________________________ Name______________________________________ Subscriber Name_______________________________ Street______________________________________ Subscriber Soc Sec#____________________________ City/State_______________________Zip_________ Subscriber ID#________________________________ Home Phone___________Cell Phone____________ Subscriber Birth date___________________________ Sex: M F Work Phone__________________ Medical insurance WILL cover eye examinations in Age_________ Date of Birth_________________ many cases. Please enter your information below so Email______________________________________ we can determine your coverage. Would you like to receive communications by: text e-mail phone Medical Insurance______________________________ Subscribers Name______________________________ Marital Status: Single Married Widowed Divorced Subscriber Soc Sec#____________________________ Soc Sec #:__________________________________ Subscriber ID#________________________________ Employer:__________________________________ Subscriber Birth date___________________________ Occupation:_________________________________ Secondary Insurance____________________________ What is the main reason for today's visit? Check one ___Annual Routine Exam (no complaints) ____Contact Lenses Which pharmacy would you like prescription ___Referral from another doctor ___Diabetes exam medications sent to: (Name and Location): ___Specific problem with eyes or vision (describe below) _____________________________________________ ______________________________________________________ _______________________________________________________ _____________________________________________ PRIVACY PRACTICE ACKNOWLEDGEMENT NEW PATIENTS ONLY Who may we thank for referring you to our office? A copy of Treasure Coast Eye Associates’ Notice of Name of friend or relative ___________________________ Privacy Practices is available for review in the waiting room. Please look over this document if you desire, and If not referred, how did you choose our office sign below that you have had an opportunity to review it. (check one and provide details) Copies are available if you would like a copy to take with Another Doctor______________________________ you. Insurance List ______________________________ ______________________________________________ Website____________________________________ Signature Newspaper/Radio/TV_________________________ ______________________________ Other _____________________________________ Date ASSIGNMENT AND RELEASE (Sign below to allow us to file your insurance) Medicare and most medical insurances do NOT pay for routine vision examinations or refractions (to determine prescription for glasses). If refraction is necessary or requested during the exam, these insurances will disallow it, stating it is a non-covered service. Therefore, the patient will be responsible for the refraction charge. The refraction charge is $35. If by chance your insurance does pay, we will refund that money to you. The practice of waiving deductible and coinsurance amounts is illegal. I understand I am responsible for these payments. I, the undersigned, certify that I (or my dependent) have insurance coverage with the companies provided and assign directly to Treasure Coast Eye Associates all insurance benefits, if any, otherwise payable to me for services rendered. I understand that my insurance contract is between me and my insurance, not Treasure Coast Eye Associates, and I am responsible for all charges whether or not paid by my insurance. If my insurance has not reimbursed this office in full within 90 days, I will be billed the outstanding balance. A 1.5% interest charge will be assessed monthly thereafter for past due balances. 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 Insured/Parent/Guardian______________________________________________ Date________________ (PLEASE FILL OUT OTHER SIDE ALSO) The information in this confidential case history form is critical to the evaluation of your vision and health. EYE HISTORY Are you experiencing any of these Have you ever been diagnosed or How long ago was Last Eye Examination?___________ symptoms since your last exam? treated for any of the following? By Whom? __________________________ (Please circle) (Please circle) Blurry Vision Glaucoma Do you wear glasses? YES NO Red Eyes Cataracts All the time Occasionally Driving Only Burning Macular Degeneration Reading Only Distance Only Double Vision Eye Injury Discharge Retinal Disease/Detachment Contact Lens Wearers Only: Flashes of Light Blindness What kind/brand of contacts do you wear? Seeing spots Eye Turn/Strabismus _______________________________________________ Dry Eye Lazy Eye/Amblyopia Cleaning solutions used: ___________________________ Tearing Diabetic Eye Problems How often do you replace your contacts? ______________ Itching Dry Eye How often do you sleep in your contacts?______________ Light Sensitivity LASIK surgery Night Vision Problems Cataract surgery Are you satisfied with the vision and comfort of your Temporary Loss of Vision Diabetic eye laser treatment current contact lenses? YES NO Other______________________ Glaucoma laser treatment Other________________________ MEDICAL HISTORY OTHER QUESTIONS Primary Care Physician__________________________________ How many hours per day are you on a computer or digital device? Last Physical Exam_____________________________________ ___________Hrs Have you ever been diagnosed or treated for any of the following health problems? (Please circle) How many hours per week to you spend outdoors? Anxiety Kidney Disease ___________Hrs Allergies Lupus/other autoimmune disease Arthritis Migraine headaches Smoking Status: (Please circle) Asthma/Emphysema/COPD Muscle/Bone problems Never Former Smoker Occasional Every Day Blood disorder Pacemaker Cancer Rheumatoid arthritis Alcohol Use: (Please circle) What kind?_________________ Shingles Never Socially Heavy Depression Skin condition High Cholesterol Stroke Diabetes: Type 1 or Type 2 Other brain disease How long diagnosed?_________ Psychological Ears/Nose/Throat/Sinus Thyroid Heart condition Pregnant What type?__________________ How many weeks?_________ High Blood Pressure Other__________________ HIV/AIDS CURRENT MEDICATIONS FAMILY MEDICAL/EYE (including eyedrops and MEDICATION ALLERGIES HISTORY over the counter) _________________________ ___________________________ Does anyone in your family have _________________________ ___________________________ any of the following conditions? _________________________ ___________________________ Please circle and list the affected family members. _________________________ ___________________________ _________________________ ___________________________ Glaucoma____________________ _________________________ ___________________________ Cataracts____________________ _________________________ ___________________________ Macular Degeneration__________ _________________________ ___________________________ Retinal Disease_______________ _________________________ ___________________________ Blindness____________________ _________________________ ___________________________ Lazy Eye/Eye Turn____________ _________________________ ___________________________ Diabetes_____________________ _________________________ ___________________________ Cancer______________________ _________________________ ___________________________ Heart Disease_________________ _________________________ ___________________________ Other_______________________ _________________________ ___________________________ ROUTINE VS MEDICAL EYE EXAM A routine eye examination is defined by insurance companies as an office visit for the purpose of checking vision, screening for eye disease and updating eyeglass and contact lens prescriptions. Routine exams have a final diagnosis of nearsightedness (myopia), farsightedness (hyperopia) or astigmatism. “Vision Plans” such as VSP, Eyemed, Spectera, Davis and others are prepaid or discount benefits usually provided by your employer or health insurance plan for the purpose of covering or discounting routine examinations, glasses and contact lenses. The plans are separate from medical or health insurance. A medical eye examination is defined by insurance companies as an office visit for the purpose of assessing, diagnosing, and/or treating an eye problem. Medical exams have a final diagnosis of conjunctivitis, dry eye, cataracts, glaucoma, diabetes, etc. These types of exams must be billed to your health or medical insurance plan, such as Medicare, Blue Cross Blue Shield, United Healthcare, etc. just like your visits to you primary care doctors and specialists. A refraction is a part of an eye exam that determines your eyeglass prescription. It typically involves looking through a device with changing lenses and involves questions like, “which is clearer – one or two?”. Vision plans and some HMO medical plans generally cover this procedure, whereas medical insurance does not. This service has a fee of $35 if it is not covered. Please supply all insurance information (vision and medical) prior to your examination. The determination of which insurance will be billed is based on the complaints addressed during the exam, testing done, as well as any
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