Patient Welcome and Medical History Form

Patient Name(Required)

First Last

Date(Required)

Date of Birth:(Required)

Age:

Social Security #:(Required)

Birth Sex:

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

If you have another address that you go to during the year please provide it below

Temporary Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

E-mail address:

Home Phone #:

Cell Phone #:(Required)

Work Phone #:

Other Phone #:

Preferred #: H / C / W / O(Required)

Would you like an appointment reminder?(Required)

Text

Call

Marital Status:(Required)

LEGALLY SEPERATED

DOMESTIC PARTNER

Name of Spouse:(Required)

First Last

Emergency Contact:(Required)

Relationship to Patient:(Required)

Phone #:(Required)

Employer:

Occupation:

Please provide your Primary and Secondary Medical Insurance. If you presented your Insurance card to the front desk please just fill in the Subscriber Name and Birth date:

Insurance Company:(Required)

Policy #:(Required)

Group #:(Required)

Subscriber Name:(Required)

First Last

Subscriber DOB:(Required)

Secondary Insurance

Insurance Company:(Required)

Policy #:(Required)

Group #:(Required)

Subscriber Name:(Required)

First Last

Subscriber DOB:(Required)

Release of HIPAA to family members: Please provide, if any, family members whom Ortiz Eye Associates may speak to regarding your care. You can revoke or change this at any time in writing.

Name:(Required)

First Last

Relationship:(Required)

Name:(Required)

First Last

Relationship:(Required)

PLEASE READ OVER ALL INFORMATION BEFORE SIGNING

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES/HIPAA

I acknowledge that I have been given the opportunity to review and/or have received a copy of Ortiz Eye Associate’s Notice of Privacy Practices/HIPAA. We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to Protected Health Information.

Signature(Required)

Date(Required)

CONTACT LENS PRESCRIPTIONS

If you are a new contact lens wearer or it has been several years since you last wore contacts, please be advised a contact lens evaluation/ fitting fee will apply as these services are not included in the general eye examination fee. A contact lens prescription will be released after the Doctor has finalized your prescription. Contact lens prescriptions are valid for one year. A signature is now required from you verifying release. Signing the bottom of this form is acceptable in releasing your prescription

SPECTACLE PRESCRIPTION WARRANTY

If you have any questions about your new glasses, please see our opticians to verify the adjustment of the glasses and for further demonstration of the optics of specialty lenses. The optometrist, at no additional cost, can verify your spectacle prescription within 60 days of the original eye examination.

FRAME POLICY

New frames purchased at Ortiz Eye Associates may be warranted. Frames that are being reused or purchased elsewhere are not guaranteed from any breakage or damage during the lens replacement process or adjustments.

MISSED APPOINTMENT POLICY

Any appointment that you fail to arrive for without calling and leaving a message or speaking to the staff will be considered a missed appointment. Missed appointments will be charged a $25 fee.

ORTIZ EYE ASSOCIATES PAYMENT & INSURANCE POLICY

Ortiz Eye Associates, unless told otherwise, will submit all medical charges to your medical benefits, this means that deductible’s, co-insurance & co-pays will apply. For in-network plans we will submit to insurance first and whatever is not paid by your insurance you, the patient, will receive a bill for. For all other charges, payment will be due the same day services are received. For out of network plans, payment is due in full the day of your appointment.

Please be aware that we are OUT OF NETWORK with all HMO plans. We also do not accept any HMO plans primary with a PPO plan secondary. Example: UHC HMO primary w/ BCBS PPO secondary. This also applies to HMO primary w/ Medicaid secondary. We do not call for any insurance coverage or benefits, it is the patient’s responsibility to contact your insurance company with any questions/benefit coverage.

We do give a 30% medical discount (vision services excluded) for all private pay patients with no insurance, out of network insurance or high deductible insurance.

Signature(Required)

Date(Required)

PATIENT SIGNATURE ON FILE/LIFETIME CONSENT AUTHORIZATION

Please Read Over All information Before Signing

I request that authorized insurance benefits including Medicare benefits be made on my behalf to Ortiz Eye Associates, P.C.

I authorize any holder of medical information about me be released to the Health Care Financing Administration and/or other insurance carrier and its agents any information necessary to determine benefits or the benefits payable for related services.

By signing this consent, 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.

For those patients of Ortiz Eye Associates, by signing this form, you understand that the “refraction” portion of your eye exam will not be submitted to insurance as it is a non-covered service and will be billed directly to you. You are also authorizing payment of insurance benefits be made either to you or on your behalf to Ortiz Eye Associates, P.C. for any services furnished to you by this office. Also, if payment for our services is denied by your insurance company, you agree to be personally and fully responsible for payment, including reasonable attorney fees and costs of collection. Venue for any such collection matters shall be in Grundy County, Illinois.

Date(Required)

Signature(Required)

Medical History Questionnaire

Name(Required)

First Last

DOB(Required)

Date of last eye exam:(Required)

REVIEW OF HEALTH SYSTEMS

EYES- Have you had or do you have any of the following?

Glaucoma(Required)

Yes

Explain:(Required)

Cataracts(Required)

Yes

Explain:(Required)

Dry Eyes(Required)

Yes

Explain:(Required)

Glasses(Required)

Yes

Explain(Required)

Contacts(Required)

Yes

Explain:(Required)

PAST FAMILY & SOCIAL HISTORY

Patient Past History

Have you had any eye operations?(Required)

Yes

Date(Required)

Type:(Required)

Have you had an eye injury?(Required)

Yes

Date(Required)

Type:(Required)

Have you had a retinal detachment?(Required)

Yes

Date(Required)

Type:(Required)

Name of family doctor?(Required)

First Last

Referring Physician:(Required)

First Last

Are you pregnant or nursing?(Required)

List any eye medications you are currently taking:(Required)

Social History

Do you use alcohol(Required)

Yes

Smoking Status:(Required)

Current every day smoker

Current some day smoker

Former smoker

Never smoked

Unknown

Do you use other substances?(Required)

Yes

What:(Required)

Describe any special visual needs:(Required)

Family History Do any family members have any of the following problems:

High blood pressure(Required)

yes

Relation:(Required)

Diabetes(Required)

yes

Relation:(Required)

Glaucoma(Required)

yes

Relation:(Required)

Macular Degeneration(Required)

yes

Relation:(Required)

Retinal Detachment(Required)

yes

Relation:(Required)

Cataracts(Required)

yes

Relation:(Required)

Other eye condition(Required)

yes

Relation:(Required)

Description:(Required)

Date(Required)

Signature(Required)