Welcome to Jessup Eye Care!
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Patient Last Name First Name Middle Name/Initial
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Street Address:
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Marital Status: m Married m Single
DOB: Month ______Day ______Year ________
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City:
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__ Male __ Female
Social Security #:
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State: Zip Code:
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E-Mail Address:
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Employed?__Yes __No Student? Yes ___No
Name of employer:______________________
May we contact you at work? __Yes __No
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Home Telephone: ______________________
Cellular Telephone: ____________________
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Work Telephone: ______________________
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Is this your first visit to our office? __Yes __No
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Whom may we thank for referring you to us?
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How did you find us?
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I understand that I am ultimately responsible for my bill and any fees associated with collecting unpaid balances. There will be a 30% processing fee plus court costs added to delinquent balances if sent to a collection agency. There will be a $20.00 charge for returned checks.
X________________________________________________________________________________ Signature (Signature of parent or guardian if patient is a minor) Date
X____________________________________________________________
Name of parent or guardian if patient is a minor
Effective Date of Notice: Jan 1, 2010
ACKNOWLEDGEMENT OF PRIVACY POLICY AND PRACTICES
I understand that in an attempt to protect the privacy of my identifiable health information, Jessup Eye Care has established a Privacy Policy and guidelines for Privacy Practices within their office(s). This information details the use and/or disclosure of information contained in my personal medical/optometric records kept for the purpose of diagnosis, treatment, payment and health care operations. In accordance with HIPAA Regulations, a copy of the Jessup Eye Care Privacy Policy and Practices has been made available to me while in the office today. Should I choose to have a personal copy, one will be given to me at no charge.
O I have read, understand and acknowledge the Privacy Policy & Practices of Jessup Eye Care.
O I have elected not to read the Privacy Policy & Practices of Jessup Eye Care.
O A copy of the Jessup Eye Care Policy & Practices was given to me today.
X______________________________________ ________________
Signature Date
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Jessup Eye Care ∙ Baptist Bellevue Medical Center ∙ 7640 Hwy 70S, Suite 204 ∙Nashville, TN 37221
IF YOU WOULD LIKE TO USE INSURANCE
PLEASE READ AND COMPLETE THE FOLLOWING
We are willing to act as your agent in obtaining maximum benefits from your insurance company. We will contact your insurance company and obtain benefit information which will be applied to your bill.
Please be aware of the following:
Not all insurance companies provide vision care. Vision care insurance covers eye exams and/or glasses and contact lenses. Major medical insurance covers eye problems (i.e. conjunctivitis), eye injuries and diseases (i.e. cataracts, glaucoma, etc.). Many times vision care insurance plans and major medical insurance plans are covered by different companies. We will submit claims for services provided to your insurance company, but you are ultimately responsible for the amounts that your insurance company does not cover. Depending on your plan or coverage, you may be instructed to pay at the time services are rendered and receive reimbursement from your insurance company.
Please fill out the following information so that we may obtain benefit information and submit your claim to your insurance carrier:
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Patient Name
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Patient Date of Birth
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Patient Social Security #
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Insured Person’s Name
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Insured’s Date of Birth
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Insured’s Social Security#
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Patient’s relationship to Insured
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Medical Insurance Name
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Medical Insurance ID Number
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Self Spouse Child Other
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Insured Person’s Employer
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Vision Insurance Name
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Vision Insurance ID Number
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I authorize the use of this form on all insurance transactions
I authorize release of information to all my insurance carriers.
I authorize my doctor to act as my agent in helping me obtain payment from my insurance carriers.
I authorize payment directly to my doctor should he/she accept assignment for such.
I understand that I am ultimately responsible for the portion of my bill that my insurance does not cover
I understand that I am responsible for my bill if my insurance doesn’t pay or respond to claims within 30 days.
Signature:_____________________________________Date:____________________________
CONSENT TO TREAT FORM & MEDICAL HISTORY QUESTIONNARIE
Name:________________________________________________________________________Date:__________________
Do you have any allergies to medications? O No O Yes If yes, please list:_____________________________
___________________________________________________________________________________________________
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies): ___________________________________________________________________________________________________
List all major injuries, surgeries, and/or hospitalizations you have had: ___________________________________________________________________________________________________
Ladies: Are you pregnant and/or nursing? O No O Yes
Please note any family history (parents, grandparents, siblings, living or deceased) for the following medical conditions:
DISEASE/CONDITION No Yes RELATIONSHIP TO YOU
Blindness............................................... O O _______________
Cataract.................................................. O O _______________
Crossed Eye.......................................... O O ________________
Glaucoma............................................... O O ________________
Macular Degeneration.......................... O O _______________
Retinal Detachment/Disease............. O O ________________
Arthritis.................................................... O O ________________
Cancer.................................................... O O ________________
Diabetes................................................ O O ________________
Heart Disease....................................... O O ________________
High Blood Pressure........................... O O ________________
Kidney Disease..................................... O O _________________
Lupus..................................................... O O _________________
Thyroid Disease.................................... O O _________________
Do you use tobacco products? O No O Yes If yes, type/amount/how long: _________________________________________
Do you drink alcohol? O No O Yes If yes, type/amount/how long: _____________________________________________
Do you use illegal drugs? O No O Yes If yes, type/amount/how long: _____________________________________________
Do you currently (or have you ever had) any problems in the following areas:
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SYSTEM
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NO
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YES
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SYSTEM
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NO
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YES
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NEUROLOGIC
Headaches/Migraines..........................
Seizures................................................
EYES
Loss/Blurred Vision..............................
Double Vision.......................................
Dryness/Redness...................................
Mucous Discharge................................
Sandy or Gritty Feeling........................
Itching/Burning/Tired Eyes..................
Foreign Body Sensation.......................
Excess Tearing/Watering......................
Glare/Light Sensitivity.........................
Eye Pain or Soreness............................
Sties or Chalazion.................................
Flashes/Floaters in Vision....................
EARS, NOSE, MOUTH THROAT
Allergies...............................................
Sinus congestion..................................
Runny nose..........................................
Chronic Cough.....................................
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RESPIRATORY
Asthma/Bronchitis...............................
Emphysema..........................................
VASCULAR
Diabetes...............................................
Heart Pain............................................
High Blood Pressure............................
Vascular Disease..................................
GASTROINTESTINAL
Diarrhea/Constipation..........................
GENITOURINARY
Genitals, Kidney, Bladder....................
BONES/JOINTS/MUSCLES
Arthritis/Joint Pain...............................
Muscle Pain.........................................
LYMPHATIC/HEMATOLOGIC
Anemia.................................................
Bleeding Problems...............................
ENDOCRINE
Thyroid/Other Glands..........................
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By signing this form, I consent to treatment for myself and/or on behalf of the Minor for whom this information pertains. I give permission for the doctor(s) to examine, diagnose, and initiate treatment as deemed appropriate. I further, attest that I am the Parent or Legal Guardian of the Minor and have the authority to authorize care and treatment. I understand that I am responsible for any charges connected with my services should my insurance not cover them.
X______________________________________________________________________________________________________
Patient/Parent or Guardian Today's Date
Lifestyle Questionnaire
Name: ____________________________________ Date: _______________________
Do you wear glasses? O No O Yes If yes, how old is your present pair? _________
Do you wear contacts? O No O Yes If yes, how old is your present pair? _________
Type of contact lenses: O Rigid O Soft O Extended Wear O Other
Are they comfortable? O No O Yes
Do you have back -up glasses? O No O Yes
Please answer the following questions with a score of 1 if this never applies to you up to a 6 if it happens all of the time.
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Headaches, sore eyes, or blurred vision..............................................................
Comprehension reduces as reading continues......................................................
Squinting or excessive blinking at desk tasks or reading.......................................
Must hold books close to face or holding face close to desk while reading..............
Loss of place while reading.................................................................................
Omitting or inserting small words while reading....................................................
Using a finger to keep place while reading............................................................
Writing crookedly..............................................................................................
Reversing words or letters while reading or writing.................................................
Difficulty in completing close work or “near vision tasks” on time............................
How long can you read comfortably without taking a break from reading?
5 15 30 60 min
Hours No limits
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Which of the following visual demands do you encounter on a regular basis? (Circle all that apply)
Artificial Lighting Computer work Potential Eye Hazards
Natural Lighting Board work Reading
Close-up work Paperwork Other: _____________________
Do your eyes seem bothered by glare from any of the following situations? (Circle all that apply)
Car Headlights Haze Traffic lights
Computer monitors Night driving Fluorescent lights
Sunshine Other: ________________________
Please list any hobbies or activities you participate in:
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Note to contact lenses wearers or those interested in contact lens options:
If you wish to have contact lenses prescribed by the doctor there is an additional charge. The amount varies depending on the contact type, complexity of your prescription needs, whether you need instruction in handling and proper care, the necessary tests to prescribe your lenses, and the degree of professional decision-making required. This charge may or may not be covered by your insurance. Ask our staff if you have any questions. I understand that I am responsible for any charges connected with my services should my insurance not cover them.
X________________________________________________________________________________________________
Signature Date
