glaucomacenter.net - New Information Form

Welcome to The Glaucoma Center, LLC
Alyson L. Hall, M.D.
Judy C. Hu, O.D.

The Glaucoma Center, LLC is an ophthalmology practice devoted to comprehensive care of the glaucoma patient. Dr. Hall is a fellowship-trained glaucoma specialist. Dr. Hu is an optometrist and an Optometric Glaucoma Society member with residency training at the Baltimore VA. The physicians along with a team of highly-trained staff provide state-of-the-art comprehensive glaucoma care.

Glaucoma is an important, under-recognized problem and our goal is to provide early detection and intervention with safe, effective medications and/or advanced surgical techniques.

Your initial consultation may last up to two hours. As your eyes will be dilated in order to evaluate your optic nerves, you may wish to bring someone to drive you home. Sunglasses are also helpful to assist with glare.

The Glaucoma Center, LLC participates with most insurance companies. If you are a member of a managed care program (HMO), you are responsible for obtaining a referral authorization from your primary care physician (PCP) for each office visit. The referral form must be given to our receptionist upon arrival, as well as your most recent insurance card and driver's license.

We have attached the necessary paperwork for your completion prior to your office visit. Bring this information with you on the first visit, as well as the following items:
1. A list of all your current medications.
2. If you are currently taking eye drops, please bring the bottles with you.
3. Your current eyeglasses, even if you don't use them, and a copy of your eyeglass prescription if you have it.
Please do not hesitate to contact our office should you have any questions. We look forward to caring for you. In addition, please visit our website at glaucomacenter.net for more information and updates regarding our practice.
PATIENT INFORMATION SHEET
WHOM MAY WE THANK FOR REFERRING YOU?
Location of Referring Doctor
PERSONAL INFORMATION
Name

First NameMiddle InitialLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Age
Sex
Marital Status
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
May we leave a voice message with medical or insurance information?
How would you like to receive appointment reminders?
How would you like to receive billing statements?
Employer
Primary Care Physician Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Name
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Pharmacy Location
Person to Contact in Case of Emergency
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
INSURANCE INFORMATION
Primary Insurance
Policy #
Subscriber Name if other than patient
DOB

MonthDayYear
Date
Secondary Insurance
Policy #
Subscriber Name if other than patient
DOB

MonthDayYear
Date
INSURANCE ASSIGNMENT AND RELEASE
I authorize The Glaucoma Center, LLC to apply for benefits on my behalf for services rendered. I request payment from my insurance company (companies) be made directly to The Glaucoma Center, LLC.

I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, for this or any related claims.

I permit a copy of this authorization to be used in place of the original. This authorization may be revoked by me at any time in writing.

I understand that nothing herein relieves me of the primary responsibility and obligation to pay for medical services provided when a statement is rendered. I acknowledge that I am financially responsible for all services rendered to me by The Glaucoma Center, LLC.
Signature of Patient / Legal Guardian
Date

MonthDayYear
Date
PATIENT'S REQUEST TO RESTRICT USE/DISCLOSURE OF PRIVATE HEALTH INFORMATION
As a patient of The Glaucoma Center, LLC, we are obligated to protect your health information. By law, we cannot discuss your health information with anyone but you unless we have written consent that authorized us to do so. If you have family and/or friends that you want us to share your personal health information with, please list them below. A child's (under age 18) health information may be discussed with their legal parent or guardian without a signed authorization.
Name of Individual
Relationship
Signed
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
Should be Empty:

Welcome to The Glaucoma Center, LLC

Alyson L. Hall, M.D.Judy C. Hu, O.D.

PATIENT INFORMATION SHEET

PERSONAL INFORMATION

INSURANCE INFORMATION

INSURANCE ASSIGNMENT AND RELEASE

PATIENT'S REQUEST TO RESTRICT USE/DISCLOSURE OF PRIVATE HEALTH INFORMATION

Alyson L. Hall, M.D.
Judy C. Hu, O.D.