Patient Intake Form

Patient Information Form

Fields marked with an * are required

First Name *

Last Name *

Address *

City *

US States *

Zip *

Cell Phone

Home Phone

Work Phone

Email *

Date of Birth *

Gender

Marital Status

Social Security Number

Primary Language

Occupation

Employer

Primary Care Physician

Primary Care Physician Address

Emergency Contact*

Phone*

Ethnicity

Race

Primary Insurance

Secondary Insurance

Vision Insurance

Primary ID / Policy #

Secondary ID / Policy #

Vision ID / Policy #

If policy subscriber/guarantor is other than the patient (minor)

Name

Phone

Relationship

How were you referred to our practice?

MOSIER EYE CENTER - Patient History Questionnaire
IMPORTANT: This questionnaire is to be reviewed at each appointment. Please answer all questions

Patient Demographics

Name

DOB

Phone

Primary Care Physician

Phone

Last Seen

Medical/Eye Information

How is your general health?

Do you have problems with any of these systems?

Gastrointestinal *

Nervous *

Endocrine (glands) *

Ears/Nose/Throat *

Urinary *

Blood/Lymph *

Cardiovascular *

Muscles/Bones *

Allergic/Immunologic *

Respiratory *

Eyes *

Headaches *

High Blood Pressure *

Mental *

Integumentary (skin) *

Diabetes *

Type

Date of Diagnosis*

Cholesterol *

Smoking *

Alcohol *

Allergies to Medication *

Do you take blood thinners? *

Specify

Current Medications (Please Include Dosage) *

Other Health Problems

Do you have any eye conditions/problems? *

Have you had any other operations? *

Do You Have?

Glaucoma *

Cataracts *

Dry Eyes *

Macular Degeneration *

Retinal Detachment *

Blurred Vision *

Wear Glasses *

Wear Contact Lenses *

Family History

High Blood Pressure *

Glaucoma *

Macular Degeneration *

Cataracts *

Retinal Detachment *

Diabetes *

PATIENT RESPONSIBILITY

Agreement of Responsibility
I understand that professional services are rendered to the patient and that the patient is responsible for charges incurred for these services. Payment for annual deductibles and coinsurance may be collected at the time of service. I understand that I am financially responsible for charges not covered by my insurance company.

(Responsibility) Patient Initial *

Consent to Treatment
I voluntarily consent to such care and treatment as prescribed by the physician as is necessary in his/her judgment.

(Consent) Patient Initial *

Release of Information/ Assignment of Benefits
I authorize use of this form on all my insurance submissions and authorize release of information to process a claim to all my insurance companies. I permit a copy of this authorization to be used in place of the original. I authorize the provider to act as my agent in helping me obtain payment from my insurance companies I understand the provider does not accept responsibility for collecting my insurance claims or for negotiating a settlement on disputed claims. I assign all rights and claims for reimbursement of expenses allowable under my insurance plan and authorize payment directly to the provider for services rendered. I understand I will receive a monthly statement for any balance due from me.

(Authorize) Patient Initial *

I have read and fully understand the above statements.

Patient E-Signature/Parent for Minor *

PATIENT CONSENT FORM

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow- up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

  • Obtain payment from third-party payers.

  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Patient Name *

E-Signature *

Relationship to Patient

Date *

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