Patient Information Today's Date(Required) MM slash DD slash YYYY Name(Required) Date of Birth(Required) Month Day Year Age(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Business PhoneCell PhoneEmail(Required) S.S.N. Please Select One(Required) Minor Married Single Divorced Widowed Mother's Name(Required) Father's Name(Required) Employer Occupation Student? Yes No Grade School How or by whom were you referred to our office? Primary Physician Physician Phone NumberName(Required) Physician Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Pharmacy Name Pharmacy Phone NumberPharmacy Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code InsurancePrimary Insurance Provider PhonePolicy/ID Number Group Number Name of Policy Holder Relationship Policy Holder S.S. Number Policy Holder DOB Month Day Year Policy Holder Employer Responsible PartyGuarantor/Name of person responsible for this account: Relationship of Guarantor to Patient Self Parent Other I certify that I have read and understand the information on this form, and have answered the questions accurately and to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I understand and agree to be financially responsible of all services rendered on my behalf or my dependents. Date(Required) MM slash DD slash YYYY Signature(Required)Date of Last Eye Exam Month Day Year Doctor Do you wear glasses?(Required) Yes No How old are the lenses?(Required) Do you wear contact lenses?(Required) Yes No If yes, what kind?(Required)SoftHardRGPDisposableDaily wearExtended wearAre you interested in contacts?(Required) Yes No Are you interested in Laser Vision Correction?(Required) Yes No Medical HistoryDo you or have had any of the following medical conditions? If yes, please explain, include date of diagnosis and medications you are CURRENTLY taking:Eye Injuries Yes No Medical Condition and date of diagnosis?(Required) Eye Surgery Yes No Medical Condition and date of diagnosis?(Required) Loss of vision Yes No Medical Condition and date of diagnosis?(Required) Glaucoma Yes No Medical Condition and date of diagnosis?(Required) Macular Degeneration Yes No Medical Condition and date of diagnosis?(Required) Cataracts Yes No Medical Condition and date of diagnosis?(Required) Retinal Detachment Yes No Medical Condition and date of diagnosis?(Required) Diabetic Eye Disease Yes No Medical Condition and date of diagnosis?(Required) Amblyopia/Strabismus Yes No Medical Condition and date of diagnosis?(Required) Dry Eyes Yes No Medical Condition and date of diagnosis?(Required) Legal Blindness Yes No Medical Condition and date of diagnosis?(Required) Any other eye disease Yes No Medical Condition and date of diagnosis?(Required) Seasonal allergies Yes No Medical Condition and date of diagnosis?(Required) Rheumatoid Arthritis, Lupus, other autoimmune disease Yes No Medical Condition and date of diagnosis?(Required) Heart disease Yes No Medical Condition and date of diagnosis?(Required) High Blood Pressure Yes No Medical Condition and date of diagnosis?(Required) Diabetes Yes No Medical Condition and date of diagnosis?(Required) Thyroid Condition: Yes No Medical Condition and date of diagnosis?(Required) Cancer Yes No Medical Condition and date of diagnosis?(Required) Asthma Yes No Medical Condition and date of diagnosis?(Required) Cholesterol Yes No Medical Condition and date of diagnosis?(Required) List medications Add RemoveList surgeries Add RemoveSocial HistoryDo you have difficulty driving during the day? Yes No Do you have difficulty driving at night? Yes No Do you drink alcohol? Yes No How many drinks a day? Do you smoke? Yes No How many packs a day? Have you ever had a blood transfusion? Yes No Date Month Day Year Work on a computer? Yes No How many hours a day? Have prescription sun glasses? Yes No How old are the lenses? Participate in recreational sports? Yes No If so, please list Do you do a lot of reading? Yes No If yes, how many hours a day? Want information on Laser Vision Correction? Yes No DemographicsWith recent changes in healthcare laws, as well as our efforts to provide the highest quality of care to our patients, Logan Eye Care has upgraded our computer system to a certified Electronic Health Care Records system.The new system will allow us to offer more comprehensive care to our patients and will also give patients easy access to their medical records. In order for us to accomplish that goal and meet the HER required guidelines, we ask that you provide us with additional information for your medical records:Preferred Language English Spanish Race (check one or more that apply) American Indian or Alaska Native Asian Black African American Native Hawaiian or Other Pacific Islander Hispanic White Ethnicity Hispanic or Latino Not Hispanic or Latino Native Hawaiian or Other Pacific Islander Preferred methods of communication Postal Telephone Email Text Do you smoke or have you smoked in the past? Yes No Previous Smoker? Yes No How many years has it been since you quit? Please list any prescription drug allergies Add RemoveName(Required) Date(Required) MM slash DD slash YYYY Signature(Required)Financial and Insurance PolicyThank you for choosing Logan Eye Care as your vision care provider. As a part of our services, we request you read and sign the following financial policy prior to services being rendered. Patient or responsible party must complete our information and insurance form before seeing Dr. Carol Logan. Full payment, co-payment, percentages and/or deductibles are due at the time services are rendered. We accept cash, checks, Visa, MasterCard, American Express and Discover. If you are purchasing eyewear or contacts, payment is due prior to any order being processed. Office Policy: Insurance is billed as a courtesy to our patients; however, the patient is the final responsible party. If your insurance has not paid within 60 days you will be notified. Returns or cancellations are made at the discretion of the office administrator and office credit will be issued in lieu of refunds. Please make your selection carefully. Minor Patients (under the age of 18): The adult accompanying a minor (patient/guardian) is responsible for full payment at the time of service. For unaccompanied minors, payment arrangements need to be made in ADVANCE and we must have parents or guardians written permission prior to treatment of a minor. Returned Checks: A $25.00 service charge will be applied to your account for returned checks. No returned checks will be re-deposited. All balances must be paid in cash or by credit card. One attempt will be made to collect this debt from the patient, if not collected within 5 days of the returned check; the account will be turned over to collection agency. We request a copy of your driver’s license for our records if you wish to make payments by check. Spectacle Prescription: Patients have 30 days follow-up care from the date of the fitting to make any changes in the prescription necessary. However, the Optician will be happy to check the prescription of your glasses against your prescription given by Dr. Logan at any time. Eye wear and contact lens prescriptions that are filled elsewhere are not warranted by Logan Eye Care. Contact Lens Patients: Additional time and testing is required for the fitting and evaluation for contact lenses. Additional professional fees will be applied, and are generally not covered by your insurance company. Patients have 30 days follow-up care from the date of the fitting to make any changes in the prescription necessary. A contact lens prescription is only valid one year from the exam date and cannot be filled once expired. Disposable contacts have been ordered and received by the patient, they cannot be returned. Emergency Visits: There will be a $50.00 fee charged above and beyond the usual and customary fees if seen outside of office hours. Eyeglass and contact lens prescriptions (when requested) are faxed by the end of each business day. Please realize that: Your insurance is a contract between you, your employer and the insurance company. We are not a party in the contract. You are responsible for all charges that are denied/not covered by your insurance company. Not all services are covered under insurances – glasses, contact lenses and/or contact lens fitting or evaluations and some procedures performed by Dr. Logan. Although we verify your coverage through your insurance company with each and every patient, verification of benefits is not a guarantee of payment from your insurance company. We request that you present a copy of your insurance card for our records if necessary or any discount plans that are being utilized. Only one insurance / discount plan is accepted, per patient, per year. Date(Required) MM slash DD slash YYYY Patient or legally authorized individual signature(Required)Name if signed on behalf of the patient Patient AcknowledgementNotice of Privacy Practices Our Notice of Privacy Practices describes in detail how your health information may be used and disclosed, and how you can access your information.By signing below, you acknowledge that you have received a copy of the Notice of Privacy Practices of Carol Logan, O.D., and Logan Eye Care.Date(Required) MM slash DD slash YYYY Patient or legally authorized individual signature(Required)Name if signed on behalf of the patient Consent of DisclosureFor Health Information For Treatment, Payment, and Health Care OperationsDuring the course of providing service to you, we create, receive, and store health information that identifies you. As our patient, we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to safeguard your confidentiality. It is often necessary to use and disclose your health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office. When it is appropriate and necessary, we provide the minimum necessary information to only those in need of your health care information.When you sign this consent document, you acknowledge and authorize that we may disclose your health information for treatment, payment for our services, and to perform health care operations that includes: The use and disclosure of your health information for treatment purposes, not only includes care and services provided here, but also disclosures of your health information, as may be necessary for you to receive follow-up care from us or another health professional. The use and disclosure of your health information for the purposes of payment, including, but not limited to, providing this information to your insurance company, third party, billing agent or other vendor for eligibility, determination of benefits, processing claims and receiving payment. We may have indirect treatment relationships with other organizations (such as laboratories and vendors) and may have to disclose personal health information for purposes of treatment, payment, or health care operations. That support personnel employed by this professional practice or any affiliated agencies, vendors or companies, including the optical personnel will have access to your health information. The payment of medical insurance benefits to Carol Logan, O.D., and Logan Eye Care, or other appointed agencies or parties who may accept assignment for services provided. You have the right to restrict or revoke this consent in writing at any time unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). By signing below, you acknowledge that you have read and understand that above information and voluntarily consent to the statements herein. Date(Required) MM slash DD slash YYYY Patient or legally authorized individual signatureName if signed on behalf of the patient Dilated Eye ExamWhy do we dilate your eye? Pupil dilation is extremely important, because it allows Dr. Logan to see all the way into the back of the eye. During a normal eye exam, the doctor will use a bright light and a lens to look into the eye, inspecting the health of the cornea, iris, and lens of the eye. However, the bright light causes the pupil to contract, making it difficult to see the back of the eye. The drops are necessary to open the pupils for a broad view of the retina, optic nerve and important blood vessels. The dilation is not only an important tool in diagnosing and documenting a multitude of eye diseases, but it can also reveal general health problems like hypertension (HBP). The dilation is considered part of the eye exam and not billed separately. Would you like your eyes dilated today, for a more comprehensive component of my eye health records?(Required) Yes No Refraction for glasses and/or contact lensesDuring a refraction, the doctor puts the instrument called a phoroptor in front of your eyes and shows you a series of lens choices. He or she will then ask you which of the two lenses in each choice looks clearer. Based on your answers, your eye doctor will continue to fine-tune the lens power until reaching a final eyeglass prescription. The refraction determines your level of hyperopia (farsightedness), myopia (nearsightedness), astigmatism and presbyopia. Unfortunately, Medicare considers this a routine test and therefore does not approve it, making it a non-covered service. Since Medicare doesn’t cover it, many commercial insurance companies follow suit and also consider it a non-covered service. Vision plans do cover the charge of the refraction. Woud you like a a refraction today, for a more comprehensive component of my eye health records?(Required) Yes No Date(Required) MM slash DD slash YYYY Signature of Patient and/or Guardian(Required)Retinal (Fundus) PhotographyDuring your eye examination, a highly specialized digital camera is used to capture images of the central and peripheral retina, optic disc, and macula. The images captured are used to aid Dr. Logan in monitoring the progression of certain eye conditions/diseases. Fundus photographs are used to document abnormalities associated with diabetic retinopathy, age-related macular degeneration (AMD), glaucoma, cranial nerves, etc. The photographs become part of your permanent record and will be interpreted and reviewed with you during the exam by Dr. Logan. We will repeat the photographs yearly to document any changes that may occur If you have a Vision Benefit Plan, the fee to include photos at your visit is $45.00. If you have medical insurance then the photos may be covered. We will review your coverage with you. It is Dr. Logan’s recommendation that the eyes be photographed for thorough documentation of your eye health.Would you like photographs of the eye as a more comprehensive component of my records.(Required) Yes No Date(Required) MM slash DD slash YYYY Signature of Patient and/or Guardian
