CURRENT MEDICATIONS

Please list all medications including vitamins, supplements and eye drops

If you need more space, please upload medication list.  You will have an option to upload any necessary documents at the end of the forms.

SYSTEMIC HISTORY

Please check all that apply and give dates where appropriate

OCULAR HISTORY

Please check all that apply and give dates where appropriate

SURGICAL HISTORY

Please list all surgeries and dates

FAMILY HISTORY

Please check all that apply

I declare that the above answers and statements are true and correct to the best of my knowledge.

Protecting the privacy and confidentiality of your health information is something we take very seriously. Everyone, from the physician to our staff, understands how important it is to protect your information.

Recently a federal law went into effect known as “HIPAA.” Among other things, HIPAA has strict requirements for protecting patient health information. This practice has made special efforts to comply both with this federal law as well as existing state patient confidentiality laws.

We would like you to understand that your medical information can only be released to you or a designated personal representative (a person with authority under State law to make health care decisions for the individual) through initiating an Access Request. If asking to have information sent to a third party, you need to use a Patient Authorization Form.

As part of our commitment to your privacy, we can provide you with a copy of “Notice of Privacy Practices.” This outlines how we will use or disclose your “protected health information.” If you would like a copy, just let our front desk know. If you have any questions about how we handle your information please feel free to talk to our privacy officer, Savannah Weaver.

By signing below, you acknowledge of receipt of the Notice.

INSURANCE CO-PAYMENTS ARE DUE AT TIME OF SERVICE

If you are insured by an insurance company that requires a referral from your primary physician, it is YOUR RESPONSIBILITY to provide us with the initial referral at the time of your visit or your appointment may have to be rescheduled. Please present all insurance cards upon check-in for EVERY appointment. Patients who do not have their insurance card(s) may be asked to reschedule their appointment.

I, the undersigned, assign directly to Sacramento Eye Consultants, all surgical and/or medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not they are paid by my insurance and it is my responsibility to pay any deductible amount, co-insurance or any other balance not paid for by my insurance . I hereby authorize the doctors to release all information necessary to secure the payment of benefits.

Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without patient consent. If you wish to have your medical information shared you must sign this form and name the members that are allowed to receive this information.

By signing this, I understand that:

• This allows for verbal communication only and not for copies of medical records.

• I have the right to revoke this authorization, in writing, at any time. However, my written revocation will not affect any information that was disclosed to the above named person(s) prior to my revocation.

Dilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to obtain a better view of the inside of your eye to check for signs of damage, systemic diseases and physical changes. Please note, there is no additional charge for having your eyes dilated.

It is highly recommended to have your eyes dilated if you are new to our office, having a surgical consultation, have not been dilated in over 2 years, or have the following risk factors:

• Medical conditions such as cataract, glaucoma, diabetes, and high blood pressure
• Recent history of trauma
• History of Retinal tear or detachment
• New onset of flashing lights, floaters or partial loss of vision
• If you have been previously diagnosed with a condition that requires dilation

Please be advised that dilating drops frequently blur vision for a length of time which varies from person to person and may make bright lights bothersome and reading things up close difficult. It is not possible for your ophthalmologist to predict how much your vision will be affected. Most people will be able to drive once their eyes are dilated. However, if you feel uncomfortable driving, or have never driven with your eyes dilated, it may be best to have a driver.

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.

Welcome to Sacramento Eye Consultants! We are dedicated to provide exceptional care and value our relationship with you. We feel a clear understanding of our office policies is important for the success of our professional relationship. Please take a moment to read our office policies. If you have any questions, please ask one of our staff members.

1.  We ask that you check in 15 minutes prior to your scheduled appointment time.Your appointment may be rescheduled if you arrive less than 15 minutes prior to your without all items necessary for your appointment. To reduce clinic delays, anyone arriving 15 or more minutes past their scheduled appointment time will be rescheduled.

2.  You must present a current active insurance card at the time of EVERY visit. If you do not have your insurance card, you will be asked to reschedule your appointment. If your insur ance lapses or you do not have active coverage, you are responsible for all charges incurred while you are without coverage. Therefore, it is important to keep our office updated on any insurance changes.

3.  All payments including co-pays, overdue balances, and private pay obligations are due at the time of your visit upon check-in. Accepted forms of payment include all major credit cards, checks, and Care Credit. If payment cannot be provided at the time of check-in, your appointment may be rescheduled.

4.  It is the patient’s responsibility to be aware of their individual insurance plan and benefits prior to their visits or surgery. This includes referrals, co-pays, deductibles, and co-insurance. If a prior authorization is required to be seen at our office and it is not received prior to the appointment, the appointment will be canceled until it is received.

5.  Your appointments are very important to Sacramento Eye Consultants. Your appointment is time with your physician reserved specifically for you. We understand that sometimes schedule adjustments are necessary. When a patient cancels without giving enough notice, they prevent another patient from being seen. If you would like to cancel or change your appointment, please call us at (916) 649-1515 at least 24 hours prior to your appointment. After two (2) missed appointments for new patients or three (3) missed appointments for established patients, the patient will be released of care from Sacramento Eye Consultants.

6.  To obtain medical records, a release form must be signed by the patient/guardian. There is a $15 processing fee. Please allow up to 30 business days for turnover.

7.  You must bring in any form you need our office to fill out on your behalf, including disability and DMV forms. Please allow up to 7 business days for processing.

8.  The Open Payments database is a federal tool used to search payments made by drug ad device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov. 

By signing this form, I acknowledge that I understand Sacramento Eye Consultants Patient Policies.

Introduction

Telemedicine involves the use of electronic communications (telephone, computer, etc.) to enable health care providers (doctors, nurses, physician assistants, and others) at a different location from the patient to share medical information with that patient for the purpose of improving access to patient care. The information may be used for diagnosis, therapy, follow-up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two-way audio and video
• Output data from medical devices and sound and video files

The electronic systems used will attempt to incorporate security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against corruption.

Expected Benefits:

• Improved access to medical care by enabling a patient to remain in his/her location while the healthcare provider provides medical information from a distant site
• Limiting the spread of COVID-19 and other communicable diseases
• Ability to obtain consultation from a distant medical specialist without traveling
• Conservation of personal protective equipment (PPE) such as gloves and masks to reduce shortages for healthcare providers
• Allow medical evaluation and management of patients who are unable to travel

Possible Risks:

As with any medical procedure, there are risks associated with the use of telemedicine. These risks include, but may not be limited to:

• Information transmitted may not be sufficient to allow for appropriate medical decision making by the health care provider. For instance, certain parameters of the eye examination cannot be tested remotely, such as eye pressure. In addition, there may be poor resolution of images. This may cause a delay in medical evaluation and treatment.
• Security protocols could fail, causing a breach of privacy of personal medical information.
• A lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other medical errors.

Patient’s Acceptance Of Risks

By signing this form, I understand that:

The laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine will be disclosed to researchers or other entities without my consent.

I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment.

I have the right to inspect all information obtained and recorded in the course of a telemedicine interaction and may receive copies of this information for a reasonable fee.

Telemedicine may involve electronic communication of my personal medical information to other medical practitioners located elsewhere, including out of state.

I understand that no results from the use of telemedicine can be guaranteed or assured.

Consent

By signing below, you consent (agree) that:

• You have read this informed consent form, or someone has read it to you.
• You understand the information in this informed consent form and all of your questions have been answered.
• You have been offered a copy of this informed consent form.

I hereby authorize Sacramento Eye Consultants to use telemedicine in the course of my diagnosis and treatment.