L. Allan Eisner, M.D.
20940 N. Tatum Blvd., Ste. 370 Phoenix, AZ 85050
Ph. 480-563-8787
Fax: 480-563-2377
PATIENT INFORMATION
Name:
Date of Birth
Address:
Ph#
City:
Gender:
State:
M
F
Marital Status
S
Zip:
M
D
Cell Ph#
W
Social Security #
Email address:
Name of Employer
Ph#
How were you referred to Dr. Eisner?
Physician Name
Patient Name
Other
Reason for today’s visit?
INSURANCE INFORMATION
Primary Insurance
Policy/Member ID #
Insured Name:
Insured Date of Birth:
Relationship to Insured:
SELF
Do you have secondary insurance?
YES
SPOUSE
CHILD
OTHER:
NO
Policy/Member ID #
Secondary Insurance
Insured Name:
Relationship to Insured:
Insured Date of Birth:
SELF
SPOUSE
CHILD
OTHER:
OTHER INJURY/ILLNESS & MEDICAL INFORMATION
Is this injury/illness related to an accident?
YES
NO
If yes:
WORK
AUTO
OTHER:
Name of Employer at time of injury:
Ph#:
Address:
Claim #:
Date of injury:
I authorize the release of any medical or other information necessary to process my medical claims. I also authorize payment of medical benefits to L.
Allen Eisner, M.D., LLC. I understand that claim determination of benefits is made by my insurance carrier and is not a guarantee of payment. I
understand that I am responsible for all deductibles, coinsurance and co-payments in accordance with Dr. Eisner’s participation with the insurance
carrier.
Patient or Authorized Party Signature:
PATIENT HISTORY
Name________________________________________ Date of Birth____________________ Age__________
Email Address________________________________ Primary Care Physician ____________________________
Social History
Marital Status M S W D
Race _____________________
Primary language spoken ________________
Do/Did you smoke cigarettes Yes No
Date stopped __________
Do you drink alcohol?
Yes No
If yes, how often?______________
Do you have any allergies to medications? Y N
Do you have any allergies to latex? Y N
If yes, what medication and what was the reaction?_____________________________________________________
Should you need a prescription, what is your preferred pharmacy:_____________________________________________
Phone:_______________________ Address or cross streets__________________________________________________
Family History
Please identify any blood related family members (mother, father, etc.) who have/had any of the following:
□ Blindness______________________________________
□ Diabetes_______________________________________
□ Retinal Detachment______________________________
□ Arthritis_______________________________________
□ Macular Degeneration____________________________
□ Thyroid Disease_________________________________
□ Glaucoma______________________________________
□ Other _________________________________________
□ Cataracts______________________________________
Medical History
Please tell us about your medical history. Do you have or have you ever had any history of:
Tuberculosis
Lung Disease
High Blood Pressure
Heart Disease
Skin Cancer
Diabetes
HIV Positive
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Liver Disease
Ulcer Disease
Tendency to Bleed
Thyroid Problems
Colon Cancer
Colitis/Irritable Bowel
Chemical Dependency
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Urinary Incontinence
Cancer
Depression
Musculoskeletal Problems
Neurological Problems
Ear/Nose/Throat Problems
Other:__________________
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
Please list any surgical procedures:
Ocular History
Please tell us about your ocular history. Do you have or have you had any history of:
Glaucoma
Y N Cataracts
Y N Chronic Eye Infection
Y N
Macular Degeneration
Y N Dry Eye Syndrome
Y N Retinopathy
Y N
Other
Please list all medications you are currently taking and the dose. Please include over the counter medication and any
products containing aspirin or ibuprofen. If you have a list we would be happy to make a copy of it.
Medicine
Dosage
Frequency
Medicine
Dosage
Frequency
Signature on File, Assignment of Benefits, Financial Agreement
Patient Name:
Patient SS#
1. AUTHORIZATION OF PAYMENT: I understand that my signature authorizes release of payment of
medical benefits from my commercial insurance carrier (including Medicare, Workers Comp or Motor
Vehicle) directly to L. Allan Eisner, MD. I understand that I am responsible for any copays, deductibles or
coinsurance as dictated by my insurance carrier.
2. FINANCIAL AGREEMENT: Any benefits of any type under any policy of insurance insuring the patient,
or any other party liable to the patient, is hereby assigned to L. Allan Eisner, MD. I agree to cooperate with
L. Allan Eisner, MD to obtain necessary healthcare service plan authorizations.
3. PAYMENT AT TIME OF SERVICES: I agree that I will pay my account at the time of service or will
make financial arrangements satisfactory to L. Allan Eisner, MD for payment if I have no insurance coverage
available.
4. DELINQUENT ACCOUNT: If my account is deliberately delinquent, I agree to pay collection agency,
attorney and court costs associated with collection on this account.
5. RESPONSIBILITY OF A MINOR: I agree that, if I and the parent/guardian bringing a child in for
treatment that I am responsible for all fees incurred by the child.
I have read and understand the above information.
__________________________________________
Patient Signature or Authorized Party
___________________________
Date
Financial Responsibility Disclaimer
Date____________________
Welcome to our office. Dr. Eisner and his staff are committed to providing top quality healthcare services while at the same time
trying to maximize the office visit experience for all our patients. As part of this commitment we would like you to have a clear
understanding in advance of your health insurance coverage and any financial obligations you might have to this office once your visit
is over.
As a ‘participating provider’ in your commercial health insurance carrier’s network Dr. Eisner has agreed to accept the fee structure
created by your insurance carrier, a fee structure that is always discounted from his usual and customary fees. Conversely, having
insurance coverage and visiting a ‘participating physician’ does not guarantee that the fees charged for your visit(s) will be
covered or paid in full by your insurance carrier.
Please understand that any remaining balance after claims processing is a determination made by your insurance carrier under its
‘covered benefits and exclusion from coverage’ section, and not a determination made by this office. Below are the reasons that you
may have an unpaid balance after your insurance claim has been processed.
1.
Any unpaid co-pay or co-insurance.
2.
Any remaining deductible balance.
3.
Any non-covered service.
4.
If Dr. Eisner is not a ‘participating physician’ with your insurance carrier.
We will do the claims processing for you and send you monthly statements regarding the status of your claim. Only after the claim
has been fully processed will you be asked to pay any unpaid balance. You will have 30 days to pay any unpaid balance before
interest of 1% a month will be added to your unpaid balance.
Signature:___________________________________________________Date:____________________________
As a courtesy we are giving you the option of providing our office with credit card information, to be used only to pay any unpaid
balances after final claims processing has been done by your insurance carrier. This will eliminate the need for you to mail us a check.
Your credit card information will be stored in a secure place and not given to any other parties.
I hereby voluntarily provide my credit card information for the expressed and exclusive purpose of paying for any unpaid insurance
claim balances arising from services provided by L. Allan Eisner MD, LLC.
VISA
MC
AMEX
Name (as appears on card) ______________________________________
Credit Card #_____________________________________________Exp. ____________ Security Code _________
Signature_____________________________________________
Date_________________________
REFRACTION CHARGES
What is a Refraction? A Refraction is a measurement performed by Dr. Eisner to determine the need for corrective
lenses (glasses or contact lenses) to maximize your visual acuity.
“Refractive services” have been designated by Medicare law as a non-covered service. Payment for non-covered
services is the patient’s responsibility. In addition, refraction is not always a covered service by commercial insurance
and would be the responsibility of the patient if so determined.
The fee for a Refraction is $75
I have commercial insurance. Will this service be billed? Yes, as a courtesy we will bill all commercial insurance for
the refraction. In the event the service is not paid, you will be mailed statement.
I have a Medicare replacement health plan. Will it pay the Refraction charge? Medicare replacement health plans
will not pay for any service determined to be non-covered by Medicare. This charge will be collected at the time of
service in addition to any copay due.
Is the refraction fee part of my annual deductible? Non-covered services do not count as part of the annual deductible
Can I choose not to have a Refraction? Yes you can, but then Dr. Eisner will not be able to determine whether you need
corrective lenses or a change in your existing prescription to maximize your visual acuity.
______ I have read and understand the above information. I am fully aware that I am responsible for the Refraction
charge and agree to pay the $75.00 fee.
___________________________________
____________________
Signature
Date
I acknowledge receipt of
NOTICE OF PRIVACY PRACTICES
On this date: ________________________________
Signature: __________________________________________
With whom, if anyone, are we able to discuss your medical care:
_____________________________________________________