Patient Paperwork

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Patient Paperwork
<II><
Please Contact Me at this Number
McCoy
VISION
Today's Date
Patient Registration
_______
Patient's Name (last, first, middle initial)
Street Address
Is P atient?
Single
City
Married
Chart#
Date of Birth
Widowed
Divorced
I
Email Address
Federal Law requires us to ask race: Hispanic
Emergency Contact (does not live with you)
Sex
State
Full-time Student
Home Phone
Zip
Work Phone
Cell Number
P art-time Student
Social Security Number
Non-Hispanic
Relationship
Referring Physician
��--
Phone #
Family Physician
Employer's Name
Street Address
Is patient's condition related to?
A. Employment
City
Business Phone
State
B. Auto Accident
C. Other Accident
Zip
If yes, explain
Date of Birth
Spouse Name (last, first, middle)
Social Security #
Date of accident
Business Phone
Spouse's Employer
If patient is a child, please complete:
DOB
SS #
State
City
Zip
DOB
Work Phone
Home Phone
Street Address
Mother's Name
SS #
Home Phone
Street Address
Father's Name
State
City
Zip
Work Phone
Complete the Insurance information below
Insurance Company
lnsured's Name
lnsured's SS#
Insurance Company
lnsured's Name
*
lnsured's SS#
Contract Number
Group
Relationship to Paitent
Does coverage include vision?
Contract Number
Group
Relationship to Patient
Does coverage include vision?
Most health insurances do NOT cover routine vision care. Vision insurance covers only routine care.
If you hav e any questions as to whether your insurance will cov er your v isit, please ask.
Patient Billing/Payment Authorization
Each patient is responsible for obtaining a referral if one is required by your insurance carrier. It is the patient's
responsibility to ensure that PatriciaM.McCoy,M.D. is a participating provider with their insurance carrier. If Patricia M.
McCoy,M.D. is a participating provider with the patient's insurance carrier, we will file your claim for your office visit or
surgery and allow 45 days for payment in full. If you do not have insurance, do not have a referral for the service date or
we are not a participating provider with your insurance carr ier, payment is expected at the time services are rendered.
Co-payments and non-covered fees, such as refraction fees, are the responsibility of the patient
and are due at the time of service.
A refraction is a reading to determine your best corrected vision. Insurance does not usually cover the cost of refractions.
It is the policy of Patricia M. McCoy, M.D. to collect all payments in full at the time of service. If your visit is a result of an
injury or accident involving a lawsuit, (excluding workers comp), we will gladly provide receipts for all services rendered
for your reimbursement.
Extended Patient Signature Authorization
Authorization for Patricia M. McCoy, M.D.
I request that payment of authorization Medicare benefits be made either to me or on my behalf to Patricia M. McCoy,
M.D. for any services or items furnished to me by the physician or supplier. I authorize any holder of medical information
about me to release to the Health Care Financing Administration or other insurance company and its agents any information
needed to determine these benefits or the benefits payable for related services.
I request that payment of (patients insurance company/companies onfile) benefits be made directly to Patricia M.
McCoy,M.D.
By signing below, I understand that routine vision care, refraction fees, diagnostic testing, and co-pays may
not be covered by my insurance carrier and I am responsible for these services at the time they are rendered.
*
Date signed
Signature of beneficiary or person signing for beneficiary
Parental Consent for the Treatment of a Minor
Please be advised that anyone seeking medical treatment or routine eye care under the age of 19 is required to have
parental consent. This consent must be given by a parent or legal guardian. Your signature below gives us consent to
provide the necessary medical care and/or vision care deemed necessary by the physician providing the care.
By signing below you additionally accept financial responsibility for the treatment of the dependant child. All co-pays
and/or fees are the responsibility of the guarantor presenting the minor for services/treatment regardless of any legal and/
or verbal agreement between the parents.
Guarantor's DOB
Guarantor's Signature
Patient's Name
M/F
Relationship of guarantor
Guarantor's Social Security#
Today's Date
Sex of the guarantor
Receipt of Notice of Privacy Practices Written Acknowledgement Form
I,
, have received a copy of the Notice of Privacy Practices.
Signature of Patient:
Date:
Signature of Guardian:
Date:
I have reviewed both sides of this questionnaire with patient
Date
MD Initials
Date
MD Initials
Date
MD Initials
YOUR PHYSICIAN WOULD LIKE TO PROVIDE YOU WITH THE HIGHEST QUALITY CARE POSSIBLE. TO ASSIST HIM/HER, WE ASK THAT YOU CO M- PLETE THE FOLLOWING HEALTH HISTORY SO THAT YOUR OVERALL HEALTH MAY BE ASSESSED AND INCORPORATED INTO YOUR E YE CARE.
MEDICAL HISTORY QUESTIONNAIRE
Sex: M
[ ] F [ ] Age:
____
Today's Date:
Current EYE Problem:
Drug Allergies:
----
Are You On Blood Thinners? Yes
Who�yourFami�Physician?
[j
No
[]
If Yes, Which?
-----
------
YOUR MEDICATIONS
List All Medications you take, including Over-The-Counter medicines and vitamins/supplements:
MEDICAL HISTORY
Do You Have a Problem With:
Yes
No
Yes
If yes, please explain
Skin Disease
Diabetes/Sugar
Head (Headaches)
Cancer
Ear/Noseffhroat/Mouth
Cholesterol
Lungs/Breathing(TB!Astbma}
No
If yes, please explain
Thyroid
_
Heart Disease
Allergies (Environmental)
High Blood Pressure
Allergies (Food)
Stomach/Intestines
Kidney Stones
Genitals/Kidney/Bladder
Urinary
Arthritis
Bleeding Disorder
Bones/Joints/Muscles
Blood (HIV/Hepatitis)
Neuro/Stroke
Infectious Disease
Lymph Nodes/Swelling
Psychiatric
_
Other Problems: Please List:
Treatment
_
_________
____________________________
OPERATIONS
List any previous operations, general and eye related
I.
2.
3.
4.
5.
Date
Complications or Difficulties
Family History and Visual Inventory
Your Eye History...
Right
Left
Right
Left
Amblyopia (lazy eye)
Muscle Disorder
Cataract
Lacrimal Obstruction
Corneal Transplant
Macular Degeneration
Diabetic Retinopathy
Retinal Detachment
Glaucoma
Iritis
Eye Injury, please provide date
_____
Describe:
-------
List all eye medications you use (including over-the-counter meds):
Have you ever worn glasses or contact lenses? Yes [] No [] How old is your prescription?
___ _
_
Are you happy with your current glasses? Yes [] No [] or Do you need an eye glass exam? Yes []
Your Family History.
Do/did any family members have? Yes
No
Father
No []
.•
Mother
Sibling
Other, explain
Blindness
Cataract
Glaucoma
Macular Degeneration
Strabismus (crossed eye)
Diabetes
Heart Disease
High Blood Pressure
T hyroid Disease
Social History.
Yes
••
Yes
No
Marital Status: S M W D
Live alone?
Nursing Home
Do you?
Smoke?
Chew Tobacco
Use Drugs?
Drink Alcohol
No
100A Providence Main Suite 1E, Huntsville, AL 35806
Fax (256) 382-2705
(256) 382-2700
<I><
McCoy
VISION
Thank you for choosing Dr. McCoy to handle your eye care needs.
We have your appointment with our office scheduled on
our
(Huntsville or Scottsboro) office.
at
in
Our Huntsville office is conveniently located on the corner of University Drive and Providence
Main. The entrance to our office is on the back east side of the building, above the CVS. If you
have any questions about our new office location or your care with Dr. McCoy, please talk to one
of our staff members about it. We will be happy to take the time to be sure your questions are
answered. You can reach our office at 256-382-2700. Please bring the following to your
appointment:
•
Your completed paperwork
•
Current medications
•
Your insurance cards
•
Your copay or deductible and $25 refraction fee if being refracted (needing a glasses
prescription), this is not included in the exam fee and is not covered by most insurance
plans
•
Your current prescription for glasses or contact lens
During your exam your pupils may be dilated and dilating drops cause a variable amount
of blurry vision for an unpredictable length of time. We cannot tell you how much your
vision will be affected and for exactly how long. Because driving safely may not be
possible after having your eyes dilated, you should make arrangements to have someone
drive you after your appointment.
Dr. McCoy is a medical physician and sees patients for both medical and vision exams. Unless you
have a known condition, we cannot determine until after you have been seen by the doctor if you
have a medical diagnosis or a (refractive) vision diagnosis, we request that you call your
insurance company to clarify any questions you may have about your medical and vision
coverage. If your insurance requires a referral please obtain your referral from your primary
care doctor prior to your visit.
Please visit our website
www.mccoyvision.org
Satellite location: 323 Parks Avenue,.., Scottsboro, AL 35768
mccoyvision.org