Patient Information Sheet

Patient Communication Preference Regarding PHI
Telephone Communication Preferences
Patient Name
Date

MonthDayYear
Date
Physician
Home #
Work #
Mobile #
Other
Email Communication Preferences
Email
example@example.com
In order to best serve our patients and communicate regarding their services and financial obligations, we will use all methods of communication provided to expedite those needs. By providing the information above, I agree that Michael Pennachio LLC, (d/b/a Pennachio Eye) or one of its legal agents may use the telephone numbers provided to send me a text notification, call using a pre-recorded artificial voice message through the use of an automated dialing system or leave a voice message on an answering device. If an email address has been provided, Pennachio Eye or one of its legal agents may contact me with an email notification regarding my care, our services, or my financial obligation.
Other than you, your insurance company and health care providers involved in your care, whom can we talk about your health care information? (Check all that apply)

SpouseCaregiverChildParentOther
I acknowledge that I have received a copy of the Privacy Notice for Pennachio Eye. I acknowledge that I have been given the opportunity to request restrictions on use and/or disclosure of my protected health information. I acknowledge that I have been given the opportunity to request alternative means of communication of my protected health
information.
Patient or Personal Representative Signature
Date

MonthDayYear
Date
Printed Name
Relationship to Patient

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION
Patient Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Cell Phone
The above listed patient authorizes the following healthcare provider to make medical record disclosure as requested:
Type of information to disclose:

All clinical medical recordsAll optical records
REQUEST TO RELEASE ALL PHI BY ELECTRONIC FILE - PDF FORMAT TO:
PENNACHIO EYE at the following email address: info@pennachioeye.com
I understand I may revoke this authorization at any time. I understand that authorizing the disclosure of this health information is voluntary and is not required as a condition for treatment. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. I understand the information in my medical record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). I also understand it may also include information about behavioral or mental health services, and treatment for alcohol or drug abuse.

I have requested my PHI in PDF/Electronic format and accept the security risks of possible disclosure breach which may be associated with unsecure, unencrypted e-mail.

I have read the above foregoing Authorization for Release of Information and acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.
Signature
Date

MonthDayYear
Date
Unless otherwise revoked, this authorization will expire on the following date:___. If I fail to specify an expiration date, this authorization will expire 1-year from the date signed.

INFORMATION REGARDING DILATING EYE DROPS
Dilating drops are used to dilate or enlarge the pupils of the eye to allow the doctor to get a better view of the inside of your eye.

Dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for your doctor to predict how much your vision will be affected. Because driving may be difficult immediately after an examination, it’s best if you make arrangements not to drive yourself.

Adverse reaction, such as acute angle-closure glaucoma, may be triggered from the dilating drops. This is extremely rare and treatable with immediate medical attention.

I hereby authorize Dr. Pennachio and/or such assistants as may be designated by him to administer dilating eye drops. The eye drops are necessary to diagnose my condition.
Patient (or person authorized to sign for patient)
Name

First NameLast Name

Explanation of Refraction Charge & Payment Terms
Please read and understand before signing. By signing this form you are acknowledging that we will collect $45.00 during your visit today.

A refraction is the method to determine the best visual acuity achievable of an individual. It is the first step in determining whether an individual has a potentially harmful medical condition relating to their eyes and vision. Also, a refraction is the process of determining if there is a need for corrective
eyeglasses or contact lenses. It is an essential part of an eye examination and necessary to write a prescription for glasses or contact lenses. For these reasons, refraction will be performed at every eye examination.

Most medical insurance plans, including MEDICARE, do NOT cover refractions or routine eye examinations. Medicare allows that we charge separately for that portion of the examination, since it is not a covered service.

Our office fee for a refraction is $45.00 and this fee is collected at the time of service, in addition to any co-payment your insurance plan may require. Refraction fees will NOT be billed to your insurance company.

If you have any questions regarding Medicare and insurance policies or procedures, please do not hesitate to ask. We will do our best to assist you.

Patient Acknowledgement

I have read the above information and understand that the refraction is a non-covered service. I accept full financial responsibility for the cost of this service and understand that payment is due at the time of service. I understand that any co-payment, co-insurance or deductible I may have are separate from and NOT included in the refraction fee.
Signature
Date

MonthDayYear
Date
Should be Empty:

Patient Information Sheet

Medical Information

Patient Communication Preference Regarding PHI

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION

INFORMATION REGARDING DILATING EYE DROPS

Explanation of Refraction Charge & Payment Terms