New Patient Forms

Dr. Shetty and the staff of Florida Eye Specialists wish to welcome you to their office.

We are here to serve you, the patient, and we want to help you understand what will take place at your first visit.  Your first visit will last 1 to 2 hours.  A complete medical and family history must be taken during your initial exam.  This includes questions about your general health, allergies, medications and past surgeries or diseases.  Please bring all of your medications, including all eye drops with you. 

Dr. Shetty will give you a comprehensive eye examination.  You should anticipate having your eyes dilated.  This will result in blurred vision for 3-4 hours.  We ask that someone be present to drive you home safely.  Additional tests may be required to document the status of your eyes, such as visual field testing and pachymetry .

We ask that you arrive 20 minutes before your scheduled appointment to allow for check-in.  Please bring your insurance cards and current valid identification to your appointment as well as the new patient paperwork.  For your convenience, the forms are available below for you to fill out prior to your visit.

 

We look forward to meeting you.  Our goal is for you to have a wonderful experience and the best possible care.

Florida Eye Specialists

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FLORIDA EYE SPECIALISTS

PATIENT INFORMATION                                                       

Date________________________________________

Patient’s Name ________________________________________________

Sex:    Male    Female 

Marital Status: _______________________________________________
Date of Birth:  __________________  Age:_________________________

Social Security #: _______________________________________________
Driver’s License #: _______________________________________________

If minor, Parent’s Name & Social Security #: _______________________________________________

Home Address:  _______________________________________________

City: ___________________ State: ______ Zip: _________

Home Phone Number: ______________________________________________
Cell/Alternate #: ______________________________________________

Email Address: ______________________________________________
May we email you? ______________________________________________

Person to contact in case of emergency: ______________________________________________

His/Her Address: ______________________________________________
Phone #: _______________________________________

Who is your Referring Doctor?______________________________________________

Referring Doctor’s Address: ______________________________________________
Phone #: ______________________________________________

Who is your Primary Care Physician (PCP)? ______________________________________________

PCP’s Address and Phone ______________________________________________

Who is your Employer (Occupation)? ______________________________________________

Business Address and Phone #: ______________________________________________

Primary Insurance: ______________________________________________

Policy #: _______________________________________________
Policy Holder’s Name: _________________________________________
Secondary Insurance: _______________________________________________
Policy #: _______________________________________________

Policy Holders Name: _______________________________________________

LEGAL GUARDIAN, SPOUSE, PARENT OR POWER OF ATTORNEY INFORMATION

Name: _________________Relationship to Patient: ________

Address:_________________________________________
Home#:__________________________________________

SSN: ____________________________________________
Driver’s License #: __________________________________

The patient or responsible party agrees to the Physician’s reasonable and customary fee for medical services.  The receptionist will accept cash, check, and credit card for routine visits as you leave.  If financial problems arise, please make arrangements or be subject to all costs of collections including, but not limited to, attorney fees, court costs and finance charges.  I authorize Florida Eye Specialists PA to release any information acquired in the course of eye exam or treatment to other physicians, etc for health reasons and consent to the useof photographs for the purpose of documentation, publication in medical journals or presentations during medical meetings.

Patient Signature ____________________ Date __________


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HEALTH QUESTIONNAIRE
           

Describe in the space below your main symptoms/problems and how long you have had them (including pain) _______________________________________________

_______________________________________________

Review of Eye History

Do you have glaucoma, or been called a glaucoma suspect or have ever taken glaucoma eye drops?

_______________________________________________

Have you had eye surgery, laser or other eye procedure? List types, dates and surgeon’s name:

_______________________________________________
Do you have glaucoma, or been called a glaucoma suspect or have ever taken glaucoma eye drops?

_______________________________________________

What eye drops or medications or supplements do you take for your eyes?

_______________________________________________

Has anyone in your family been diagnosed with any of the following eye diseases? And who was diagnosed?

Glaucoma  Blind (unknown)/Other Macular Degeneration or Retinal Detachment ______________________________________

Review of Medical History

Are you allergic to any medications? _______________________________________________

Please list all major illnesses, hospitalizations, and surgeries with their approximate dates:

 

Please list all of the medication you take on a regular basis:

 

Social History:  Do you smoke?  Yes  Quit – How long ago? __  Never       

  Do you drink alcohol? Never Rarely  Occasionally Daily

Review of Overall Health

General  ÿ Fever ÿ Chills ÿ Loss of weight ÿ Loss of weight ÿ Loss of sleep
ÿ Headache    ÿ Scalp Tenderness

Ear, Nose and Throat ÿ Jaw pain  ÿ Difficulty swallowing ÿ Ringing in ears
ÿ Loss of hearing ÿ Sinus problems

Cardiovascular/Pulmonary  ÿ Chest pain ÿ Shortness of Breath ÿ Irregular heart beat    ÿ Poor circulation  High blood pressure ÿ Low blood pressure

Gastrointestinal/ Genito-Urinary  ÿ Frequent urination ÿ Poor appetite
ÿ Excessive thirst

Muscle/Bone/Joint  ÿ Pain ÿ Weakness  ÿ Numbness Which area?

Skin    ÿ Bruise easily ÿ Itching/rash  ÿ Hay fever  ÿ Hives  ÿ Skin cancer

Neurologic ÿ Depression ÿ Dizziness/Fainting

Patient Signature ________________________Date ______

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OUR FINANCIAL POLICY     

 

   Thank you for choosing Florida Eye Specialists as your healthcare provider. We are committed to providing the best medical care possible.

   Please understand that payment of your bill is essential for us to continue our services.  Accordingly, we ask all of our patients to pay for their care at the time they receive their services.  The following statement explains our Financial Policy which we ask you to read, sign and return to us prior to your treatment.  A copy will be provided to you upon request

   All patients should provide accurate and complete personal and insurance information prior to being seen by the doctor.  All applicable co-pays, personal balances, both current and prior, are due at time of service.  We accept cash, check, Visa, Master Card, & American Express.

Regarding Insurance

   We participate in most insurance plans, including Medicare.  For some insurance companies, we accept assignment of benefits, but in ALL cases we require that the guarantor, the person who is financially responsible, is personally liable for all balances not covered by insurance.

   If you are NOT insured by a plan we do business with, OR if you are insured by a plan we do business with, but do not have an up-to-date driver’s license and current valid insurance card to provide proof of insurance, payment in full is expected at each visit. 

   Please be aware that some, and perhaps all, of the services provided may be non-covered services or may not be considered medically necessary under the Medicare Program or by other insurance companies. You must pay for these services in full at the time of visit.

 

Usual and Customary Rates

    We are committed to providing the best treatment for our patients and we charge what we believe to be reasonable and customary fees for our region and specialty. If your insurance company uses a different fee schedule, you will be responsible for any balance remaining.

 

Claims Submission

    We will submit our claims and assist you in any way we reasonably can to help you get your claims paid.  Your insurance company may need you to supply certain information directly.  It is your responsibility to comply with their request. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.  If your insurance company does not pay our claim within 45 days the balance will automatically be billed to you.

 

Coverage changes   

   If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.  If your insurance company does not pay your claim within 45 days, the balance will automatically be billed to you.

 

Missed Appointments/No Show Policy

    Unless cancelled at least 24 hours in advance, our policy is to charge $15.00 for a missed appointment.  Please help us to serve you better by keeping scheduled appointments.  This fee is not covered by insurance so it will be your personal responsibility.

 

Past Due Accounts

    Accounts are considered past due after 90 days.  Patients who are sent additional statements will have a statement handling fee of $15 charged to each statement.  Overdue accounts will be referred to a collection agency along with the issuance of a 1099 to the IRS for cancellation of a debt.  Fees that we pay to secure past due balances will be added to your account.  Once an account has been referred to collections, Florida Eye Specialists will terminate the patient relationship and only continue services for thirty days (30) for emergencies and only on a cash basis.

 

Co-Payments and Deductibles

    All co-pays and deductibles must be paid at time of service.  This arrangement is part of your contract with your insurance company.  Failure on our part to collect co-payments and deductibles from patients can be considered fraud.  Please help us in upholding the law by paying your co-payments at each visit.  If co-pay balances are not paid on date of service, a $15.00 fee will be charged to your account.  This fee is not covered by insurance.

 

Returned Checks

    Checks returned for any reason will be assessed a $15.00 fee in addition to the fees charged by the bank. These fees are not covered by insurance. The amount of the check will be expected to paid immediately with either a credit card, cash or cashier’s check.

 

Consent for Medical Treatment

    I am the patient or the patient’s duly authorized representative, and do hereby voluntarily consent to and authorize care encompassing all diagnostic and therapeutic treatment regimens necessary in the judgment of my provider, for myself, my minor child, or other.  I am aware that the practice of medicine is not an exact science.  I acknowledge that no guarantees have been made to me as a result of treatments or performed examinations.

 

   I do hereby authorize the release of medical information necessary to file a claim with my insurance company and assign benefits otherwise payable to me and to Florida Eye Specialists.

 

   I also authorize the following individuals to have access to my account and/or medical records: ________________________________________________

 

    I have read this form completely, have had the opportunity to ask questions, and have been fully informed as to the contents of this agreement.

Patient Signature ______________________Date__________

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REFRACTION POLICY

Upon your visits at Florida Eye Specialists, it may be necessary to perform a refraction.  While Medicare and some major insurance carriers do not cover this, a refraction is important in determining your potential vision and in medically diagnosing causes of vision loss.

FREQUENTLY ASKED QUESTIONS

1.       What is a Refraction, and why do you charge for it?

You may know the test as a way to evaluate your need for glasses.  This is true, but it can also detect vision loss.  Some vision loss is slow and progressive and the patient may not even notice. For this reason, a physician will check the patient’s vision by refracting them.  The test can also uncover other problems a patient may be unaware of and is important in determining a patient’s eye health.

 

2.       Why is this charge separate from the exam?

Medicare has deemed that a refraction is not a medical service and therefore not a covered service.  Medicare does acknowledge that this is separate to the rest of the eye exam and therefore, there is a separate fee for this service.  Most insurance companies have followed Medicare’s lead and do not cover the refraction, because they consider the test to be “vision care” and unrelated to the office visit.  However, this is the only way to detect some types of vision loss.

 

3.       Do you have to charge for the refraction?

The answer is yes, especially for Medicare patients.  The Office of Inspector General has deemed that not charging for a provided service is an “inducement” to the patient and therefore illegal.  The Federal Government insists that if an exam, procedure or test is performed, it must be charged for.  They do this because they are worried that some physicians may try to lure patients by offering them an incentive such as a reduced fee, and want it to be a fair playing field for all physicians who accept Medicare.  We are obligated by the government to charge for all of our services.

Please be aware that when we call to verify your benefits, your healthcare insurance company discloses to us that verification of benefits is not a guarantee for payment.  Payment will be finalized according to your plan’s benefits when your healthcare insurance company receives and processes the claim.

 

ACKNOWLEDGEMENT

I have read the above information and understand that the refraction is a non-covered service.  I accept full financial responsibility for the cost of the refraction and agree to pay for the refraction at the time of service.  Any co-payments due are separate from and not included in the $50 fee for the refraction.

Patient Signature _____________________Date___________

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NOTICE OF PRIVACY PRACTICES

I have been provided the opportunity to read, or it has been read to me, the Notice of Privacy Practices at Florida Eye Specialists

 

I understand that Florida Eye Specialists is committed to treating and using protected health information about me responsibly.

 

I understand my rights as it relates to my records at Florida Eye Specialists and understand how information about me may be used and disclosed.

 

I understand that my health record is the physical and legal property of Florida Eye Specialists, but the information belongs to me. I may have access to inspect, amend, or obtain a copy of my health information. Costs will incur for copies of my records, and written requests must be made with the Privacy Officer to inspect, access or possibly amend my health information.

 

I understand that Florida Eye Specialists is required to maintain the privacy of my health information. Florida Eye Specialists will require my authorization to release my health information to outside sources with the exception of disclosures for purposes of treatment, payment and healthcare operations. These may include: access to my health information by Florida Eye Specialists staff and physicians; billing to me or a third party payer; in addition, business associates of Florida Eye Specialists may have access to my health information. I am assured that proper business associates agreements are in place, insuring the protection of my health information. Upon the physicians best judgment, we may disclose to a family member, relative or close personal friend or any other persons you identify, health information relevant to that persons involvement in my care. Health information may be used for research data, organ procurement, marketing, FDA, public health or legal authorities; and or law enforcement purposes.

 

Florida Eye Specialists may call or write me with appointment reminders, cancellations and may leave voice mail messages at my home or place of employment.

 

I have read and understand the Health Information Practices of Florida Eye Specialists, P.A.

 

Patient Signature __________________Date ____________

Please read the complete HIPAA Notice of Privacy Acts prior to signing this acknowledgment.