Patient Registration Form
Name
First Name
Middle Initial
Last Name
Sex:
Male
Female
Date of Birth:
-
Month
-
Day
Year
Date
Age:
Soc. Sec. #:
Marital Status:
Single
Married
Divorced
Widowed
Other
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Tel:
Format: (000) 000-0000.
Cell Tel:
Format: (000) 000-0000.
Work Tel:
Format: (000) 000-0000.
Texting OK?
Yes
No
(For appointment reminders only)
Email Address:
example@example.com
Employment Status:
Full Time
Part Time
Homemaker/
Student
Active Duty Mil.
Retired
Employer:
Occupation:
How did you hear about us or who referred you?
Who is your Primary Care Doctor?
Insurance Information:
Insurance Type:
Insurance Type 2:
Insurance Type 3:
Policy #:
Subscriber Name:
First Name
Last Name
Subscriber Date of Birth:
-
Month
-
Day
Year
Date
Soc. Sec. #
Are you interested in learning more about Laser Vision Correction?
Yes
No
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List any medications you currently take (prescription and over-the-counter):
Do you have new allergies to any medications, since your last visit?
YES
NO
If YES, list medications:
List all major illnesses (glaucoma, diabetes, high blood pressure, heart attack, etc.) or injuries (concussion, etc.)
List any surgeries you have had (cataract, tonsillectomy, appendectomy, etc.):
DO YOU CURRENTLY HAVE ANY PROBLEMS IN THE FOLLOWING AREAS?
Rows
YES
NO
Details
Since when?
Loss of vision
Blurred vision
Fluctuating vision
Distorted vision (halos)
Glare or light sensitivity
Loss of side vision
Double vision
Dryness
Mucous discharge
Redness
Sandy or gritty feeling
Itching
Burning
Foreign body sensation
Excess tearing or watering
Eye pain or soreness
Infection of eye or lid
Tired eyes
Crossed eyes, lazy eye
Drooping eyelid
ALLERGIC/IMMUNOLOGIC (sneezing, swelling, redness, itching, hives, etc.)
CARDIOVASCULAR (high BP, racing pulse, etc.)
GENERAL/CONSTITUTIONAL (fever, weight loss, other)
ENDOCRINE (diabetes, hypothyroid, etc.)
GASTROINTESTINAL (stomach upset, diarrhea, constipation, etc.)
GENITAL, KIDNEY, BLADDER (painful urination, frequent urination, impotence, etc.)
BLOOD/LYMPH (cholesterolemia, anemia, etc.)
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Rows
YES
NO
Details
Since when?
IMMUNOLOGIC (mumps, chickenpox, measles, etc.)
SKIN (pimples, warts, growths, rash, etc.)
MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling, cramps, etc.)
NEUROLOGICAL (numbness, headache, etc.)
PSYCHIATRIC (anxiety, depression, insomnia, etc.)
RESPIRATORY (asthma, COPD, bronchitis)
Rows
YES
NO
RELATIONSHIP TO PATIENT
Blindness
Glaucoma
Arthritis
Cancer
Diabetes
Heart disease or high blood pressure
Kidney disease
Lupus
Stroke
Thyroid disease
Other
SOCIAL HISTORY
Do have difficulty when driving?
YES
NO
Do you have problems with night vision?
YES
NO
Have you ever tried to wear contact lenses?
Have you ever tried to wear contact lenses?
YES
NO
Do you currently wear glasses?
YES
NO
(If yes, how long have you had your current prescription?):
Do you drink alcohol?
YES
NO
If YES:
occasional
1/day
2-3/day
4+/day
Do you smoke?
YES
NO
If YES:
If YES:
½ pack/day
1 pack/day
1+pack/day
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Our Financial Policy
We are dedicated to providing the best possible care for you, and we want you to completely understand our financial policy.
1. Payment is due at the time of service unless arrangements have been made in advance by your insurance carrier. We accept Cash, Personal Check, American Express, Discover, Visa and MasterCard.
2. Keep in mind that your insurance policy is basically a contract between you and your insurance company. As a service to you, we will file your insurance claim if you assign the benefits to the doctor—in other words, if you agree to have your insurance company pay the doctor directly. If your insurance company does not pay the practice within a reasonable time period, we will have to look to you for payment. If we later receive a check from your insurer, we will refund any overpayment to you.
3. We have made prior arrangements with many insurance companies and other health plans to accept an assignment of benefits. We will gladly bill them directly for services rendered, however you are required to pay a co-payment at the time of your visit.
4. If you are insured by a plan that we do not have a prior arrangement with, we will prepare and send the claim for you on an unassigned basis. This means the insurer will send the payment directly to you. Therefore, our charges for your care are due at the time of service.
5. Not all insurance plans cover all services. In the event your insurance plan determines a service to be "not covered," you will be responsible for the complete charge. Payment is due upon receipt of a statement from our office.
6. We will bill your insurance company for all services provided in the hospital. You are responsible for any balance due. I have read and understand the practice's financial policy and I agree to be bound by its terms. I also understand and agree that such terms may be amended by the practice from time to time.
(A) FINANCIAL RESPONSIBILITY AGREEMENT:
I hereby authorize my insurance company to pay the proceeds of any benefits directly to Dr. Michael A. McMann, MD., LLC. / McMann Eye Institute. A copy of this can be used as an original for insurance purposes.
I agree to pay my co-payment portion as services are provided. If there is any remaining balance owing, I agree to pay promptly upon receipt of a statement. I am aware of the additional charge for returned checks of $25.00.
(B) ACKNOWLEDGEMENT OF PRIVACY NOTICE:
I have been provided an opportunity to read and review the NOTICE OF PRIVACY PRACTICES; or to receive a copy per my request ($0.50) as required by The Health Insurance Portability and Accountability Act (HIPAA).
Patient's Signature / Legal Guardian Signature
Date
-
Month
-
Day
Year
Date
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