Patient Demographic and Health History Form

Patient Demographic and Health History Form

Please fill out prior to your FIRST visit OR If you are a current patient and need to update your information
Patient's Name:*
Date of Birth*

MonthDayYear
Date
Sex*

FemaleMaleOther
Race:*
Ethnicity:*

HispanicNon-HispanicPrefer Not To Disclose
Preferred Language:*
Social Security Number:
Address:*

Address

Street Address Line 2

CityState/Zip Code

Postal / Zip Code
Landline Phone Number:

Area CodePhone Number
Work Phone Number:

Area CodePhone Number
Mobile Phone Number:

Area CodePhone Number
Employer:
Email:
example@example.com
Spouse's Name:
Spouse's Date of Birth:

MonthDayYear
Date
Spouse's Phone Number

Area CodePhone Number
Is the Emergency Contact the same as Spouse?

YesNo
Emergency Contact Name:
Emergency Contact Relationship to Patient:
Emergency Contact Phone Number:

Area CodePhone Number
How did you hear about our office?*

Family/Friend, word of mouthOutside ProviderInsurance CompanyPhone BookInternetOther
Referring Doctor:
Primary Care Physician:*
Other Physicians (please list with first and last name):
Optometrist:
Last Eye Exam Date:

MonthDayYear
Date
I currently wear or utilize:

GlassesReadersSoft Contact LensesGas-Permeable Contact LensesOther
Parent/Guardian Name (if patient is a minor):
Parent/Guardian Phone Number:
Patient/Guardian Date of Birth:

MonthDayYear
Date
Parent/Guardian Email:
example@example.com
Parent/Guardian Employer:
Consent to Text or Email for Reminders and Other Healthcare Communications

By initialing below, I agree to Des Moines Eye Surgeons communicating by SMS text message and/or email. I confirm that the mobile number is correct, and I will notify the practice of any changes. I am aware that I can withdraw consent at any time by informing the Des Moines Eye Surgeons. I understand that this request to receive text messages will apply to all future appointment reminders/health information unless I request a change by notifying the Des Moines Eye Surgeons.
Preferred Contact Method for Appointment Reminders:*

Text MessageEmailMobile Phone CallLandline Phone Call
I am open to receiving healthcare related text messages/emails, which may include appointment reminders, bill pay reminders or a post-appointment survey.*

YESNO
I am open to receiving marketing related text messages, which may include promotional discounts.*

YESNO
HEALTH HISTORY

Have you ever been diagnosed with the following:
Diabetes:*

Type 1Type 2Pre-DiabeticNone of the above
Diabetes:

Diet-controlledOral Medication-ControlledInsulin-ControlledNone of the above
HIV/AIDS*

YESNO
Have you ever been diagnosed with any eye conditions below (check all that apply):*

CataractsDiabetic RetinopathyMacular DegenerationCorneal ProblemsGlaucomaRetinal DisordersNone of the aboveOther
Other medical conditions you would like the doctor to be aware of (please list):
Patient's Surgeries/Hospitalizations (please list incident and date):
Patient's Drug Allergies (please list):
Social History
Caffeine Use*

YESNO
Caffeine Quantity per Week
Tobacco Use*

YESNO
Tobacco Quantity per Week
Alcohol Use*

YESNO
Alcohol Quantity per Week
Have you received your pneumonia vaccination?*

YESNO
Family History

(Identify blood relatives with the following)
Diabetes

FatherMotherGrandparentSibling
High Blood Pressure

FatherMotherGrandparentSibling
Stroke

FatherMotherGrandparentSibling
Heart Disease

FatherMotherGrandparentSibling
Glaucoma

FatherMotherGrandparentSibling
Macular Degeneration

FatherMotherGrandparentSibling
Medications

List all the medications you are currently taking. Please include vitamins and supplements. We can also take a copy of your personal list if you have one once you're in the office.
Pharmacy name:
Pharmacy address/location:
Name of Medication and Dosage (amount/how often)
Authorization to Disclose Protected Health Information (PHI)

I authorize Des Moines Eye Surgeons/Eye Designs’ to speak to the following people regarding my health information as deemed necessary. This authorization will not expire unless revoked or terminated by the patient or the patient's personal representative by submitting a written revocation to our office.
I consent to my health information being discussed via the methods below with myself or my PHI contacts indicated below:*

Text MessageEmailPhone Call
Spouse's Name:
Other (name, relationship, phone number):
(POA, children, parents, relatives, etc.)
PATIENT ONLY
Dilating Eye Drops

Dilating eye drops are used to enlarge the pupils of the eye to allow the doctor to examine the inside of your eye. The drops frequently blur vision for a period of time and may make bright lights bothersome. Because driving may be difficult immediately after your exam, it’s best to make arrangements not to drive yourself.
Lost or Stolen Items

Des Moines Eye Surgeons is not responsible for lost or stolen items left by a patient within our office.
Service Animals

Des Moines Eye Surgeons is committed to providing individuals with disabilities full and equal access to services and treatment. Service animals are permitted in all patient areas provided the service animal does not fundamentally alter DMES’s operations or procedures. A service animal is individually trained to do work or perform tasks for a disabled person.
Patient Acknowledgments

1) I hereby certify that to the best of my knowledge all the information I have furnished on these forms are complete, true and accurate. 2) I authorize my doctor and/or such assistants to administer dilating eye drops as needed today and all future exams. 3) I hereby acknowledge that I have received or have been given the opportunity to receive a copy of Des Moines Eye Surgeons/Eye Designs’ Notice of Privacy Practices. 4) I hereby acknowledge the violation of any of Des Moines Eye Surgeons’ policies and procedures may result in termination of my relationship with Des Moines Eye Surgeons.
Name of Patient/Guardian*
Patient/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Patient Insurance Information

Please fill in if there has been a change in your coverage or you are a new patient. We can also collect this over the phone prior to your visit if that it easiest for you.
Primary Vision Insurance
ex: Avesis, Eyemed, VSP (Vision Service Plan) ...
Primary Vision Insurance Policy Holder's Information
ex: John Smith, 9/18/1979, Spouse /or/ Self
Primary Vision Insurance ID Number
this may be the primary policy holder's SSN or employee ID
Primary Medical Insurance
ex: UHC, Wellmark, Medicare, AARP Medicare Complete, Aetna...
Primary Medical Insurance Policy Holder's Information
ex: John Smith, 9/18/1979, Spouse /or/ Self
Primary Medical Insurance ID Number, Group Number
ex: 97980432, 108000
Secondary Medical Insurance
ex: UHC, Wellmark, Medicare, Mutual of Omaha, AARP, Aetna...
Secondary Medical Insurance Policy Holder's Information
ex: John Smith, 9/18/1979, Spouse OR Self
Secondary Medical Insurance ID Number, Group Number
ex: 97980432, 108000
Des Moines Eye Surgeons Financial Policy
Your Responsibility You are financially responsible for the services we provide to you. We understand that many patients arrange for insurance companies to pay for a large portion of medical care. However, the patient (or legal guardian) is ultimately responsible for the bill if the insurance company does not pay. As a courtesy to you, we will file a claim to your primary and secondary insurance plans.

Payment of co-payments are collected at the time of check-in.

Insurance has asked that we collect the patient’s out-of-pocket responsibility at the time of service. We will bill your insurance carrier for the remaining cost according to their fee schedule’s allowed amount.

Be prepared to provide your current insurance information with the Check-IN Assistant. Your Check-IN Assistant will take copies of all your active medical insurance cards (primary/secondary/tertiary) and will collect any active vision plan insurance information as well. We participate with most medical insurance plans; however, we only participate with three vision plans: VSP, Avesis, and EyeMed. Please advise us of any address, phone number or insurance changes promptly.

If you are unsure of your financial responsibility, please contact your insurance company in advance to obtain this information. Any balance remaining after insurance has paid their covered portion will be due upon receipt of a statement.

PLEASE NOTE: If you have a medical diagnosis associated with your exam, your exam charges will be submitted to your medical insurance AS REQUIRED, NOT your vision insurance.

Medicare patients Des Moines Eye Surgeons accepts Medicare assignment. You are responsible for the applicable coinsurance, deductibles and charges for non-covered services. Refractions are NOT covered by Medicare and some commercial carriers; therefore, a payment of $45 is included in your out-of-pocket responsibility on the day of service at CHECK-IN. In addition to the bill we send, you should also receive an explanation from Medicare indicating how much you owe.

I request that payment of authorized Medicare benefits be made on my behalf to Des Moines Eye Surgeons, for services furnished me by Des Moines Eye Surgeons. 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 the 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 or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Des Moines Eye Surgeons accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance and noncovered services. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier.

I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the CMS-1500 form or elsewhere on other approved claim forms, 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 Des Moines Eye Surgeons, if possible or otherwise to me.

Patients without insurance We are pleased to be able to provide services to patients that do not have insurance. However, you will be expected to pay for all services prior to being seen per our cash-pay fee schedule.

Private insurance patients Des Moines Eye Surgeons accepts assignment for most major insurances. You will be required to pay applicable co-pay amounts at the time of service and you are responsible for any coinsurance, deductibles and for all unpaid non-covered services.

Workers compensation. Des Moines Eye Surgeons accepts workers compensation. Please contact your adjuster to obtain prior approval and a listing of approved providers.

Medicaid patients. If Des Moines Eye Surgeons participates with your Medicaid assignment, a current Medicaid card must be presented at each visit and you will be required to pay the co-pay at the time of service, if required by your plan. If you have exceeded the legislative limits for the year per Medicaid, you will be held responsible for the charges. If you have a Medicaid HMO please bring your referral from your primary care physician to see the specialist physician.

HMO patients. If Des Moines Eye Surgeons participates with your insurance, you will be required to pay the applicable co-pay at the time of requested service. When required by your HMO plan, you are responsible for obtaining a referral from your primary care physician. If you do not have a proper referral, you may be required to reschedule your appointment. If services are rendered without a valid referral authorization you will be expected to sign a waiver and be responsible for full payment.

Liability insurance. If you are involved in an accident, we will be pleased to provide medical care for you. We do not, however, file claims to third-party liability insurance plans. We will either file the claim with your personal medical insurance or we will expect your payments for all balances incurred.

Methods of payment. We accept cash, check, Carecredit, VISA, MasterCard, and Discover. We do not accept post-dated checks, nor will we hold checks for any length of time. Payment arrangements may be made as necessary by calling 515-225-3546.

Returned checks. There will be a $25 fee assessed for any and all checks returned from your bank for any reason.

Prior balance: Patients with a prior balance at the time of services are requested and will be asked to pay in full prior to being seen. If the balance cannot be paid in full, then you will speak with a financial counselor to make payment arrangements prior to your appointment.

Contact Lens Fittings/Rechecks: The process of measuring the curvature and size of the cornea to determine proper fit of new or existing contact lenses is called a “Fit” or “Contact Lens Recheck”. There will be a fee to assess the fit of your current contact lenses or to re-fit you to a different lens. The fee is based upon the type of contact lenses required and if the patient is an established or new patient within our office.

Collection procedures. Members of our billing department are always available to help you with questions and/or payment arrangements. Once made in writing, agreements are binding. We consider payments by the patient for services to be an important part of the patient’s role in the patient/physician relationship. Prompt payment for services rendered is expected and failure to comply or respond to repeated communication from our office may result in discharge from the practice and/or involvement of an outside collection agency. Once an account has been rendered to an outside agency, prior balances must be resolved before being seen by a provider.

I have read and understand the DMES financial policy. I agree to assign insurance benefits to Des Moines Eye Surgeons whenever applicable. I also agree I will be responsible for fees not covered by insurance.
Name of Patient/Guardian*
Signature of Patient/Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Demographic and Health History Form

Consent to Text or Email for Reminders and Other Healthcare Communications

HEALTH HISTORY

Social History

Family History

Medications

Authorization to Disclose Protected Health Information (PHI)

Dilating Eye Drops

Lost or Stolen Items

Service Animals

Patient Acknowledgments

Patient Insurance Information

Des Moines Eye Surgeons Financial Policy