chandlereyecenter - Patient Information

Chandler EYE Center

Robert C. Davidson, M.D.
Insurance Information
REPONSIBLE PARTY INFORMATION (If not the patient)
Name

Last NameFirst NameMiddle Initial
Sex

MaleFemale
Date of birth

MonthDayYear
SSN
Address

Apt / Unit #

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
Phone Number (Primary)

Area CodePhone Number
Phone Number (Secondary)
Language

EnglishSpanishOther
Relationship to Patient
PRIMARY INSURANCE
Name of Insurance Co.
Policy #
Policy Holder’s Name
Group #
Relationship to Patient
Date of Birth

MonthDayYear
Please upload copies of your primary insurance card

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SECONDARY INSURANCE (If Applicable)
Name of Insurance Co
Policy #
Policy Holder’s Name
Group #
Relationship to Patient
Date of Birth

MonthDayYear
Please upload copies of your secondary insurance card

Browse Files

Cancelof
MEDICARE PATIENTS ONLY
Working Aged
End Stage Renal Disease
Auto No Fault Insurance
MSP Workers Compensation
Federal
Black Lung
VA
Disability Insurance
Other/Liabilities

Chandler EYE Center

Robert C. Davidson, M.D.
OFFICE POLICIES AND PROCEDURES

Thank you for choosing Chandler Eye Center as your vision care provider. We are committed to providing you with the best possible care.

REQUIRED AT CHECK IN:
- Verify/Update contact information
- Current medical insurance card
- Current valid picture ID
- Any co-payment and/or outstanding balance
CO-PAYMENTS

Your insurance company requires us to collect co-payments at the time of service. Waiver of co-payments may constitute fraud under state and federal law. If you do not have your co-payment, your appointment may be rescheduled.

INSURANCE

While, filing insurance claims is a courtesy that we extend to all of our patients, all charges are your responsibility from the date services are rendered. We strongly encourage patients to phone their insurance provider to inquire if Dr Robert C. Davidson NPI #1003809641 is an in-network provider. In order for us to file a claim on your behalf, you must present a CURRENT copy of your insurance card(s) at each visit and communicate any changes in your personal information.

Not all services are a covered benefit, so it’s very important that you understand the provisions of your individual policy. You are responsible for the unpaid balance of your visit including deductibles, coinsurance, and non-covered services.

MISCELLANEOUS CHARGES

Return check fee: $25.00. Motor vehicle/FAA Paperwork: $25.00. Medical Records (paper copies): $0.25 per page. Accounts 90 days past due may be sent to a collection agency & have a 33% surcharge added to cover additional costs along with possible removal from the practice.
Printed Name
Signature

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Date

MonthDayYear
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patients Rights section describing your rights under the law. You have the right to review our notice before signing the acknowledgement. By signing this form, you acknowledge that you had the opportunity to review the Chandler Eye Center Notice of Privacy Practices describing the use and disclosure of protected health information about you for treatment, payment, health care operations, and other uses and disclosures as stated in our Notice. We provide this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION UPON REQUEST
I,
give my permission to disclose protected health information from my health record, including financial information, to the following people:
Name(s):
Patient Signature

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Date

MonthDayYear
AUTHORIZATION TO ASSIGN BENEFITS AND STATEMENT OF FINANCIAL RESPONSIBILITY

I authorize and request that the payment of Medicare and/or insurance benefits be made directly to Chandler Eye Center. If my health insurance will not allow direct payment to Chandler Eye Center or if Chandler Eye Center chooses not to accept assignment of medical benefits, I agree to immediately forward to Chandler Eye Center any and all health insurance payments I receive. This also applies if coverage is provided by Medicare, a Health Maintenance Organization, a Worker’s Compensation policy, or any other third-party payers. I acknowledge that I am responsible for all charges for services provide by Chandler Eye Center, including any non-covered services or amounts not paid by insurance.
Printed Name
Signature

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Date

MonthDayYear
Relationship to Patient (If other than patient)
AUTHORIZATION FOR TREATMENT

I authorize the health care providers at Chandler Eye Center, to perform diagnostic procedures and treatments as may be necessary for proper medical care for myself or dependent.
Printed Name
Signature

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Date

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Relationship to Patient (If other than patient)

Chandler EYE Center

Robert C. Davidson, M.D.
TO OUR PATIENTS

IMPORTANT INFORMATION

ABOUT NON-COVERED/OUT OF POCKET EXPENSES

Refraction/Eyeglass Prescription Policy

A refraction is the process to measure the refractive error of the eyes. This measurement is used to determine your eyeglass and/or a contact lens prescription. Medicare considers this a non-covered service, as do most insurance companies. It is the policy of Chandler Eye Center to only charge the fee if an eyeglass or contact lens prescription is being provided to the patient. The following are the fees associated with the Refraction Policy:
- Eyeglass Prescription: $50.00
- Contact Lens Fitting: $50.00
Fees are collected on the day of service. Should your insurance cover this refraction process, we will reimburse you after payment has been received from the insurance company.

A refraction is not required. If you prefer not to have a refraction performed, please inform the technician.

By signing this form, I am stating that I have read and understand the above policy.
Signature

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Date

MonthDayYear

HEALTH HISTORY QUESTIONNAIRE
Date of last eye exam

MonthDayYear
Do you have any allergies to medications or substances (including latex)?

YesNo
If YES, explain
Social History
Do you drink alcohol?

YesNo
If yes, how much?
How often?
Do you use tobacco?

YESNOFORMERLY
If yes, how much?
If formerly, how long?
When did you stop?

Please list ALL current medications (Prescription/Non-Prescription):

	Name	Dosage	Route of Administration
1
2
3
4
5
6

Chandler EYE Center

Robert C. Davidson, M.D.
Chandler EYE Center
Robert C. Davidson, M.D.

CANCELLATION/NO SHOW POLICY

Thank you for trusting Chandler Eye Center as your vision care provider. When an appointment is scheduled with Dr. Davidson, time is set aside to provide the highest quality eye care. However, we do understand that unexpected circumstances may arise. Should you need to cancel or reschedule an appointment, please promptly contact our office. A timely cancellation allows us an opportunity to provide care for another patient.

WE REQUIRE A 24 HOUR NOTICE FOR CANCELLATIONS OR RESCHEDULING
- 1^ST No Show or Cancellation without sufficient notice: $50.00
  ➢ This fee is not covered by your insurance.
  ➢ This fee will be due upon scheduling your next visit. (If there are extenuating circumstances, the fee may be waived.)
- 2^nd No Show or Cancellation without sufficient notice: $75.00
  ➢ This fee is not covered by your insurance.
  ➢ This fee will be due upon scheduling your next visit. (If there are extenuating circumstances, the fee may be waived.)
- 3^rd No Show or Cancellation without sufficient notice:
  ➢ Chandler Eye Center reserves the right to terminate its doctor/patient relationship with you. We value our patients and it would grieve us to take these steps.
By signing this form, I am stating that I have read and understand the above policy.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

	SELF	FAMILY	N/A
Cataract
Glaucoma
Macular Degeneration
Retinal Detachment
Strabismus (Eye Muscle)
Amblyopia

	Yes / No	Additional Information
Diabetes
Thyroid Problems
High Blood Pressure
Pacemaker
Irregular Heartbeat/A-fib
Shortness of Breath
Asthma
Hearing Impairment
Joint Pain
Arthritis
Back Problems
Headaches
Stroke
Allergies
Blood Disorders
Cancer
Intestinal Problems
Fatigue

Chandler EYE Center

PATIENT INFORMATION

Chandler EYE Center

Insurance Information

REPONSIBLE PARTY INFORMATION (If not the patient)

PRIMARY INSURANCE

SECONDARY INSURANCE (If Applicable)

MEDICARE PATIENTS ONLY

Chandler EYE Center

OFFICE POLICIES AND PROCEDURES

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION UPON REQUEST

AUTHORIZATION TO ASSIGN BENEFITS AND STATEMENT OF FINANCIAL RESPONSIBILITY

AUTHORIZATION FOR TREATMENT

Chandler EYE Center

TO OUR PATIENTS

IMPORTANT INFORMATION

ABOUT NON-COVERED/OUT OF POCKET EXPENSES

HEALTH HISTORY QUESTIONNAIRE

Social History

Chandler EYE Center

Eye Health History

Chandler EYE Center

Chandler EYE Center

	Surgery	Year
1
2
3
4
5
6