Queenston Eye Care

Welcome,

Thank you for choosing Queenston Eye Care Center, by completing this patient information form you will help us serve you more efficiently. Should you have any questions concerning our professional services or office procedures, please feel free to ask a member of our front office staff.

Patient Information Date: ______________

 

Last Name: __________________________First Name: ___________________________     Middle: ______

Address: ___________________________________City:_______________ State: _______   Zip: _________

Email Address: _________________________________ SS#: _____-______-_____ DL#: _______________

Date of Birth: ____/_____/______ Age: ______ Sex:   M / F  

Occupation: _________________________ Employer: _______________________________________

Cell phone: (______) _________________ Home Phone: (_____) ________________

Check Appropriate Box:    c Minor     c Single     c Married     c Widowed     c Separated     c Divorced

Spouse or Parent’s Name: ______________________________

Person to contact in case of emergency: _____________

________________________ Phone: _____________

Reason for today’s visit: ______________________________________ Date of last eye exam: ____/____/___

Age of current glasses: _______________________ Type of glasses: _________________________________

List of medications if any: ___________________________________________________________________

 

 

INSURANCE INFORMATION:      ____ No Vision Insurance     ____ Discount Plan    ____ Claim Form Given

Primary Insurance

Insurance Name: ___________________ID#:______________ Group ID: _____________ Policy Holder:____________

Secondary Insurance

Insurance Name: ___________________ID#:______________ Group ID: _____________ Policy Holder:____________

 

 

Please circle any of the medical problems that apply to you or your immediate family

 

Diabetes       Self        Family None High Blood Pressure Self Family     None 

Thyroid Disease    Self        Family None Cardiovascular Disease Self Family     None

Glaucoma       Self        Family None Respiratory Problems Self Family     None     

Lazy Eye       Self        Family None Retinal Detachment Self Family     None

Cataracts       Self        Family None Head/ Eye Injury Self Family     None

Double Vision       Self        Family None Macular Degeneration Self Family     None

Cancer       Self        Family None Headaches/ Migraines Self Family     None

Major Surgeries    Self        Family None Lasik (Refractive) Surgery Self Family     None

 

 

Acknowledgement of the Federal HIPPA Privacy Practices

I acknowledge that I have received and/or reviewed a copy of the HIPPA Privacy Practices.

Signature: _______________________________________        Date: _______________

 

 

 

Financial Policy

 

Thank you for choosing Queenston Eye Care. We are committed to providing you and your family with the best available medical care. In our ongoing process to make sure that all your medical needs are met, our billing department is available to discuss our fees and this policy with you.

We ask that all responsible parties read and sign our financial policy as well as complete the patient information forms prior to seeing the physician.

Payment for all services will due at the time services are rendered. In order to serve you better we accept cash, check Visa, MasterCard and Discover.

As the responsible party, please understand (please initial by the following):

_____ 1. Your insurance policy is a contract between you, your employer and the insurance company. We are not a party to that contact. Our relationship is with you, not your insurance company. We will not become involved in disputes between you and your insurer regarding deductibles, co-payments, covered charges, secondary insurance and “usual customary” charges. As your medical provider, we will only supply factual information to facilitate claim processing.

_____ 2. Fees for services, which include unpaid balances, deductibles, and co-payments, are due at the time of services. Return checks and unpaid balances may be subject to collection placements and collection fees of  $25.00.

_____ 3. All charges are your responsibility, whether you’re insurance company pays or does not pay. If your insurance carrier does not remit payment within sixty days, the balance will be due in full from you. If any payment is made directly to you for services billed by Queenston Eye Care, you recognize an obligation to promptly remit payment to Queenston Eye Center.

_____ 4. We will only file the first two insurances; if you have more than two you will be responsible to file the rest.

_____ 5. All Medicare and Medicare Advantage patients will be responsible for the refractive charge of the exam. Medicare does not cover any procedure that is routine. If your Sup will cover it you are responsible for filing it.

_____ 6. Forms/Letters- We will be happy to complete forms and write medical letters for you upon your request. The fee of this service varies depending on the forms are $15.00 per form, and the payment is collected when you pick up the form(s). Please allow 10 business days for us to complete the form. Medical letters printed on company letterhead are $10.00 per letter and payment is also collected when you receive the letter.

_____7. Medical Records – Please remember that payment is due at the time of service.

_____8. Third Party Liability – We do not file insurance claims for third-party accidents, (i.e. motor vehicle insurance or property insurance). You will be asked to make full payment at the time of service, and you will need to file the claim with the insurance company.

_____9. Pls. circle (1) dilation or (2) Optomap ($39.00), or (3) VF screening ($29.00)

_____10.There will be no refund after 24 hours payment. For any examinations and products.(instore credit only )

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Signature: _______________________________________        Date: _______________