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. MEDICARE: I request that payment of authorized Medicare Benefits be made on my behalf to L. Allan
Eisner, MD. I authorize any holder of medical information about me to release to Medicare and its agents,
any information needed to determine these benefits or the release of medical information necessary to pay the
claim. If I have other insurance coverage, my signature authorizes releasing the information to the insurer or
agency. L. Allan Eisner accepts the Medicare allowed charge determination of the carrier as the full charge,
and I am responsible only for the deductible, coinsurance and non-covered services. Coinsurance and
deductibles are based upon the charge determination of the Medicare 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.
I have read and understand the above information.
____________________________________________________
Patient Signature or Authorized Party
___________________________
Date
MEDICARE DEDUCTIBLE POLICY
What is Medicare’s deductible? The Medicare deductible is the first $140 of physician fees in the calendar year.
If this is your first visit to a doctor’s office Medicare requires that you meet your deductible requirement at the
time of your visit. Once your deductible is met Medicare will then pay 80% of all allowable charges for
physician related services. If you have secondary (gap) insurance they may pick up the 20% balance. Medicare
has decreed that each Medicare beneficiary is responsible for any unpaid deductible and any amounts not paid
by your secondary insurance.
Will my secondary insurance company pick up my deductible expense? Most secondary insurance companies
will not pick up the annual deductible expense.
What if my secondary insurance company does pay the annual deductible? This office will issue a refund to
those eligible beneficiaries.
I have read this notice and recognize that I am responsible for any and all deductible and Refraction fees not
paid by Medicare or my secondary insurance.
SIGN______________________________
PRINT_____________________________
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:
_____________________________________________________