New Patient Information Forms - georgiaeyeassociates.com

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby give my consent for Georgia Eye Associates to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). (Georgia Eye Associates' Notice of Privacy Practices provides a more complete description of such uses and disclosures.)

I have the right to review the Notice of Privacy Practices prior to signing this consent Georgia Eye Associates reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to:
Georgia Eye Associates Privacy Officer
771 Old Norcross Road, Suite 150
Lawrenceville, GA 30046

With this consent, Georgia Eye Associates may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results, among others. With this consent, Georgia Eye Associates may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements, as long as they are marked Personal and Confidential.

With this consent, Georgia Eye Associates may email to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Georgia Eye Associates restrict how it uses or discloses my PHI to carry out TPO; however, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement

By signing this form, I am consenting to Georgia Eye Associates' use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Georgia Eye Associates may decline to provide treatment to me.

Electronic signature of Patient or Legal Guardian (click and drag mouse to sign)

Clear

Patient's Name

Date

Name of Legal Guardian

PATIENT INFORMATION

Location

First Name

Last Name

MI

Address

Home Phone

Social Security Number

Patient Employed By

Occupation

Business Phone

Patient Gender

Male Female

Age

Date of Birth

Marital Status

Cell Phone

Email Address

Person to Notify in an Emergency

Emergency Contact Phone

INSURANCE INFORMATION

Complete only if you have made prior arrangements with receptionist to file insurance.

Name of Primary Insurance Company

Name of Secondary Insurance Company

PLEASE NOTE: WE FILE INSURANCE AS A COURTESY FOR OUR PATIENTS. WE DEAL WITH OVER 700 INSURANCE CARRIERS AND IT IS IMPOSSIBLE FOR US TO KNOW THE SPECIFIC DETAILS ON HOW EACH INSURANCE WORKS. IT IS YOUR RESPONSIBILITY TO KNOW THE SPECIFICS OF YOUR PLAN. WE SUGGEST YOU CALL YOUR INSURANCE CARRIER BEFORE YOUR VISIT TO SEE IF: 1) THE PROVIDER YOU ARE SEEING IS A COVERED PROVIDER; 2) YOU HAVE A DEDUCTIBLE TO MEET BEFORE YOUR INSURANCE PAYS; AND, 3) YOUR INSURANCE COMPANY REQUIRES A REFERRAL FROM YOUR PRIMARY CARE PHYSCIAN BEFORE BEING SEEN. IF THE PURPOSE OF YOUR VISIT IS A ROUTINE EYE EXAM, MAKE SURE YOU HAVE ROUTINE VISION COVERAGE.

ASSIGNMENT AND RELEASE: I HEREBY AUTHORIZE MY INSURANCE BENEFITS BE PAID DIRECTLY TO THE PHYSICIAN AND ACKNOWLEDGE THAT I AM FINANCIALLY RESPONSIBLE FOR ANY NON-COVERED SERVICES OR UNPAID BALANCE, AND ANY LEGAL FEES NECESSARY TO COLLECT THE UNPAID BALANCE. I ALSO AUTHORIZE MY PHYSICIAN TO RELEASE ANY INFORMATION REQUIRED IN PROCESSING OF THESE BENEFITS.

Electronic signature (click and drag mouse to sign)

Clear

Date

Method of Payment

Cash Check Credit Card Other: ‎

NEW PATIENT HISTORY RECORD

PAST EYE HISTORY

CURRENT EYE MEDICATIONS

PAST MEDICAL HISTORY

TUBERCULOSIS

Yes No

CANCER

Yes No

DIABETES

Yes No

BLOOD DISORDERS

Yes No

HEART DISEASE

Yes No

HIGH BLOOD PRESSURE

Yes No

KIDNEY DISEASE

Yes No

THYROID DISEASE

Yes No

LUNG DISEASE

Yes No

NEUROLOGIC DISORDERS

Yes No

OTHER (DESCRIBE)

MAJOR SURGERIES (DESCRIBE)

Please list all current medications with strengths and your schedule, and pharmacy information

PHARMACY NAME

Phone

City

Please list all allergies to medications and/or substances:

FAMILY HISTORY

Do any major illnesses or eye diseases run in your family?

Yes No

If yes, explain

SOCIAL HISTORY

Do you smoke?

Yes No

If yes, how much?

Do you drink alcohol?

Yes No

If yes, how much?

Have you ever used drugs?

Yes No

If yes, explain

Have you ever had a blood transfusion?

Yes No

REVIEW OF SYSTEMS

Do you currently have any of the following problems?

CHRONIC FEVER, UNEXPECTED WEIGHT LOSS/GAIN, FATIGUE

Yes No

If yes, explain

EAR/NOSE/THROAT PROBLEMS (e.g., hearing loss, sinus problems, sore throat)

Yes No

If yes, explain

HEART PROBLEMS (e.g., chest pain, irregular heart beat)

Yes No

If yes, explain

RESPIRATORY PROBLEMS (e.g., shortness of breath, wheezing, coughing)

Yes No

If yes, explain

GASTROINTESTINAL PROBLEMS (e.g., heartburn, abdominal pain, diarrhea, vomiting)

Yes No

If yes, explain

URINARY PROBLEMS (e.g., pain or discomfort, blood in urine)

Yes No

If yes, explain

SKIN PROBLEMS (e.g., rashes, excessive dryness)

Yes No

If yes, explain

MUSCULOSKELETAL PROBLEMS (e.g., muscle aches, joint pain, swollen joints)

Yes No

If yes, explain

NEUROLOGIC PROBLEMS (e.g., numbness, weakness, headaches, paralysis)

Yes No

If yes, explain

PSYCHIATRIC PROBLEMS (e.g., depression, anxiety)

Yes No

If yes, explain

ALLERGIC PROBLEMS (e.g., hay-fever, sinus problems, runny nose)

Yes No

If yes, explain

Email Address

Are you interested in learning more about LASIK laser vision correction?

Yes No

REFERRAL INFORMATION

Family/friend name

Referring doctor's name

Referring optometrist's name

Insurance referral

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Drove by/walked by Christ the King ad Mercer University Health Fair Tucker Day

Health Fair - other

Internet referral

Georgia Eye Associates website Google Yahoo Other

Review website

Yellow Pages Yelp Google

Other (please explain)

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By providing my phone number, I consent to receive SMS text messages from Georgia Eye Associates for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. Privacy Policy