summerlinvision.vegas - Patient Information Form

Patient Information
Name:

First NameMiddle NameLast Name
Preferred Name:
Soc. Sec. #
Birthday:

MonthDayYear
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex:

MaleFemale
Home #:
Cell #:
Work #:
Email:
Marital Status:

SingleMarriedChild
Occupation/School:
Employed by:
Whom may we thank for referring you?
Notify in case of emergency:
Phone #:
Insurance Information
Medical Insurance:
Subscriber Name:

First NameMiddle NameLast Name
Subscriber SSN:
Birthday:

MonthDayYear
Insurance Company:
Group Name:
Group #:
Member # or ID #:
Effective Date:

MonthDayYear
Vision Insurance:
Subscriber Name:

First NameMiddle NameLast Name
Subscriber SSN:
Birthday:

MonthDayYear
Insurance Company:
Group Name:
Group #:
Member # or ID #:
Effective Date:

MonthDayYear
Name of additional patients insured under these plans:
Authorization
We realize understanding your insurance coverage can be quite challenging. We do our best to verify your eligibility and benefits. This however is not a guarantee of benefits or payment from your insurance company. Unfortunately, detailed information is not always disclosed by your insurance company. We encourage you to become familiar with your policy’s exclusions, deductible, coinsurance, and frequency limitations. It is the patient’s responsibility to ensure correct and complete Insurance information is provided before or on the date they are to be seen. Please understand after your insurance processes your claim there may be a remaining balance left on your account that you will be responsible for.
I certify that I, and or my dependent(s) have insurance coverage and assign reimbursement all insurance benefits directly to Summerlin Vision. I authorize the use of my signature on all insurance submissions and release all information necessaryto secure the payment of insurance benefits.I choose to pay for services at the time services are rendered in full and bill my own insurance.I do not have vision insurance and will pay in full at the time services are rendered.
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by Drs. Alan & Civia McCaffrey to help determine appropriate treatment. If there is any change in my personal, insurance or medical status, I will inform Summerlin Vision. By signing this I consent to treatment provided by Summerlin Vision.
Signature:

Clear
Date:

MonthDayYear
Health History
Primary Care Physician:
Phone #:
Date of last visit:

MonthDayYear
Date
Are you currently under physician care?

YesNo
Describe:
Have you ever used bis-phosphonate medication? (Fosamax, Actonel, Atelvia, Didronel, Zometa, Boniva)

YesNo
Check the box if you have any of the following:

No health concernsCirculatory ProblemsHerpesRheumatic feverAbnormal bleedingCongenital heart diseaseHigh blood pressureSexually transmitted diseaseAidsCortisone treatmentJaundiceSinus troubleAnemiaDiabetesKidney diseaseSkin rashArthritis/RheumatismEmphysemaLiver diseaseStrokeArtificial heart valveEpilepsyLow blood pressureSwollen feet or anklesArtificial JointsFainting or dizzinessMitral valve prolapseSwollen neck glandsAsthmaGlaucomaNervous problemsTaking birth controlBack problemsHeadaches/migrainesNursingThyroid problemsBlood diseaseHeart attackPregnantTonsillitisCancerHeart murmurPsychiatric careTuberculosis (TB)Chemical dependencyHeart problemsRadiation treatmentTumor or growth in head & neckChemotherapyHepatitisRespiratory diseaseUlcersOther
Medications and Allergies
Currently taking any medications?

YesNo
If yes, list them:
Have you ever taken an antibiotic prior to treatment?

YesNo
No known allergiesLatexPenicillinCodeineLocal anestheticSulfaOther
Signature:

Clear
Date:

MonthDayYear
Date
Patient Name:

First NameMiddle NameLast Name
Birthday:

MonthDayYear
Date
Short Notice Cancellation/Missed appointment Policy:
Initial
A short notice cancellation is any cancellation within 48 hours of appointment time.

We understand that occasionally circumstances arise that don’t allow you to be present for an appointment. We charge a $50 minimum fee for the first broken appointment, $100 minimum fee for the second broken appointment, and after the 3rd such instance, we may request you make arrangements to have your optometric care with another office. Broken appointments may require pre-payment to reserve future appointments.
Insurance:
Initial
It is your responsibility to provide all necessary insurance eligibility, identification, authorization and referral information and to notify our office of any changes that may occur immediately. We require photo identification when accepting insurance information. It is the patients responsibility to know if our office is participating or non-participating with their insurance. Failure to provide all required information may necessitate patient payment in full for all services. When insurance is involved, we are contractually obligated to collect co-payments, co-insurances, and deductibles, as outlined by your insurance plan. Our office collects patient’s portions at the time of service or to reserve a treatment appointment. Insurance is a benefit to help defray the cost of your treatment and is a contract between you, your employer and the insurance company. As a courtesy, we will bill your insurance for any services rendered, as you provide us with the necessary information. The treatment we recommend will always be based on your individual needs not your insurance coverage. Please understand that your insurance company does not cover all essential services. Your insurance carrier may deny services that are not a benefit or deny services as unnecessary; the services rendered will be your responsibility.
Financial Policy:
Initial
We accept local checks with a picture ID, Visa, Mastercard, American Express, Discover and cash. There is a $35.00 charge for all returned checks. Regardless of insurance coverage the patient/responsible party is ultimately responsible for all services rendered. If the insurance payment has not been received within 60 days of the date of service, any balance remaining is due and must be paid in full and may be increased by minimum rebilling fee of $5 or a monthly interest charge of 2.2% (26.4%APR).
I understand an estimated portion is due at the time of service, however if my account has a remaining balance/credit after the insurance processes my claim I authorize Summerlin Vision to charge/credit the difference to my credit card. Any amounts over $25.00 I will be notified prior to charging my card on file being charged.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
As our patient we want you to know we respect the privacy of your Personal Health Information (PHI) and will do all we can to secure and protect it. It is our policy to properly determine appropriate uses of PHI in accordance with the government rules, laws, and regulation. When it is appropriate and necessary, we provide the minimum necessary information only to those we feel are in need of it regarding treatment, payment, or health care operations, in order to provide health care in your best interests. Under the law, they are not required to obtain patient consent to use this information.

You may refuse to consent to the use or disclosure of your personal health information, but this must be provided to us in writing. Under the HIPAA laws, we have the right to refuse to treat you should you choose to refuse to disclose your PHI.

By signing below you acknowledge that you have read and understand the notice of privacy practices and all policies escribed above.
Patient or Guarantor Signature:

Clear
Date:

MonthDayYear
Date
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

Individual refused to signCommunications barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther
Please verify that you are human*
Should be Empty:

Patient Information

Insurance Information

Authorization

Health History

Medications and Allergies

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

For Office Use Only