PATIENT REGISTRATION FORM ALESSIO EYE MD, INC
PATIENT
NAME____________________________________________________BIRTHDATE______________
ADDRESS____________________________________CITY_________________ZIP_____________
HOME PHONE_____________________WORK_________________MOBILE___________________
SOCIAL SECURITY#_____________________MARITAL STATUS (CIRCLE)
SPOUSE’S NAME______________________________
S M D W
EMAIL ADDRESS________________________________________How would you like to receive
confirmation calls and educational materials? EMAIL_____________TEXT_____________
MAY WE LEAVE MESSAGES WITH OTHER FAMILY MEMBERS AND/OR ON YOUR ANSWERING
MACHINE OR VOICEMAIL?______YES______NO
EMPLOYER NAME & ADDRESS_______________________________________________________
OCCUPATION____________________________________
EMERGENCY CONTACT NAME______________________________PHONE__________________
IF MINOR: PARENT(S)/GUARDIAN NAME_______________________________________________
ADDRESS IF DIFFERENT____________________________________________________________
FATHER BIRTHDATE_________________________________SS#____________________________
MOTHER BIRTHDATE________________________________SS#____________________________
FATHER WORK PHONE_______________________________
MOTHER WORK PHONE______________________________
PRIMARY CARE PHYSICIAN NAME____________________________PHONE#_________________
MAY WE PROVIDE HIM/HER WITH YOUR MEDICAL HEALTH INFORMATION?____YES____NO
WHOM MAY WE SPEAK TO ABOUT YOUR MEDICAL HEALTH INFORMATION: LIST ALL
NAMES_____________________________________________________________________________
________________________________________________________________________________
INSURANCE INFORMATION: INSURANCE COMPANY NAME_______________________________
SUBSCRIBER NAME______________________________SS#_______________________________
SUBSCRIBER BIRTHDATE_________________________
SECONDARY INSURANCE COMPANY NAME____________________________________________
SUBSCRIBER NAME______________________________SS#_______________________________
SUBSCRIBER BIRTHDATE__________________________
CONSENT FOR ASSIGNMENT OF BENEFITS: I consent to assign all payments for these services
to this practice. I understand that I am responsible for all co-payments, deductibles, and other
amounts that may be deemed my responsibility by the payment sources as required by my
contract with my insurance plan(s) and state regulation. I further understand that my contract
with my insurance entity may or may not cover these services. It is my responsibility to obtain
information from my health plan about service coverage. If I seek care outside of the contract, I
am aware that I may be responsible for all charges that are incurred.
PATIENT/GUARDIAN INITIALS__________________
DATE_____________________
COPY OF THE PRACTICE PRIVACY NOTICE RECEIVED SIGNATURE_______________________
PRIVACY CONSENT- FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
This consent is required by the Health Insurance Portability and Accountability Act of 1996 to
inform you of your rights for privacy with respect to your health care information.
I hereby give my consent to Alessio Eye MD, Inc to use and disclose my protected information for
the purpose of treatment, payment, and operation of my health care and this practice.
Consent for treatment: I, with my signature authorize this practice and any employees working
under the direction of the physicians, to provide medical care for me, or to this patient for which I
am the legal guardian. This medical care may include services and supplies related to my health
and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative,
maintenance, palliative care, counseling, assessment or review of physical or mental
status/function of the body and the sale or dispensing of drugs, devices, equipment or other items
required and in accordance with a prescription. This consent includes contact and discussion
with other health care professionals for treatment and care.
Consent for release of information for payment and operations: I also authorize this practice to
furnish information to the identified insurance carrier(s) for any and all payment activities. I
further consent to the use for any practice operational needs as identified in the practice privacy
notice.
Consent related to the Privacy Notice: I have had a chance to review the Practice Privacy Notice
as part of this registration process. I understand that the terms of the Practice Privacy Notice may
change and I may obtain these revised notices by contacting the practice by phone or in writing. I
understand that I have the right to request how my protected health information (PHI) has been
disclosed. I also have the right to restrict how this information is disclosed, but this practice is not
required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by
that agreement.
I understand that this practice may refuse me services if I refuse to sign this consent. I may
revoke this consent at any time, but the practice may refuse services at that time. If I revoke this
consent, the revocation does not take effect until the practice receives it.
PATIENT/
GUARDIAN____________________________________________DATE__________________
IF GUARDIAN RELATIONSHIP TO
PATIENT________________________________________________
PATIENT UNABLE TO SIGN PRIVACY STATEMENT DUE
TO__________________________________
REVOCATION: I hereby revoke the consent given above.
PATIENT/GUARDIAN_________________________________________DATE______________
ALESSIO EYE MD, INC
1754 ROYALTON ROAD
STRONGSVILLE, OH 44136
(440) 238-5030
Patient’s Name________________________________________________________Date__________
NOTICE OF EXCLUSION FROM HEALTH PLAN BENEFITS
Health insurance does not pay for all of your health care costs. Medicare only pays for covered
benefits. Some items and services are not insurance benefits and your insurance plan will not pay for
them.
When you receive an item or service that is not a covered benefit, you are responsible to pay for it,
personally or through any other insurance that you may have.
The purpose of this notice is to help you make an informed choice whether or not you want to
receive these items or services, knowing that you will have to pay for them yourself. Before you
make a decision about your options, you should read this entire notice carefully.
Ask us to explain, if you do not understand why your insurance will not pay.
Ask us how much these items or services will cost you (ESTIMATED COST: $_____________)
YOUR HEALTH PLAN MAY NOT PAY FOR:
a. Refraction (calculation of your glasses prescription)
b. OCT screening
c. Screening fundus photos
BECAUSE IT DOES NOT MEET THE DEFINITION OF ANY COVERED BENEFIT:
a. Your insurance plan prohibits payment for most screening tests.
b. Your diagnosis although helpful for your eye health, is not covered by insurance plans for this
particular test.
YOUR HEALTH PLAN WILL ONLY PAY FOR:
Medically necessary tests as an adjunct to diagnosing, managing and treating disease. Insurance does not
cover screening tests taken as baseline documentation of a healthy eye or as preventative medicine to
screen
for potential disease.
I UNDERSTAND AND AGREE:
DATE__________SIGNATURE OF PATIENT______________________________________________
DATE__________SIGNATURE (of person acting on patient’s behalf)____________________________
MEDICAL vs VISION INSURANCE
Patient Name:____________________________
Date:________________
Do you have vision/optical coverage? ___ Yes ___ No
Are you being seen for a wellness, preventive, or routine examination? ___Yes ___No
One of the most challenging billing issues in an ophthalmology office is whether we should be
billing the medical or vision plan.
An ophthalmologist is a medical doctor (just like your family doctor or cardiologist) and
provides very comprehensive, medical eye exams. However, ophthalmologists also provide
routine vision exams for people with no eye disorders.
For Patients with both Medical and Vision Coverage
Your vision insurance is intended to provide you with a baseline eye evaluation. If you are being
evaluated for medical reasons (corneal disorders, diabetes, cataracts, glaucoma suspect, double
vision, etc.), you are being provided with medical care. Your vision company doesn’t provide
coverage for medical care. Therefore, we will be billing your medical insurance for visits related
to medical complaints and problems.
For Patients with no Vision/Optical Coverage
If you are being seen for a routine eye evaluation and don’t have vision/optical coverage, your
medical insurance will not pay for the eye exam. However, if you have a medical problem
(corneal disorders, diabetes, a lazy eye, cataracts, glaucoma suspect, double vision, etc.), your
visit is considered a medical problem and can be billed to your medical plan(s).
Also, please be aware that many plans are no longer paying for eye exams because of a diagnosis
of blurred vision or a headache. They are considering this a routine vision exam and are often
not paying for the visit.
Even though our staff will determine the appropriate plan to bill after your evaluation, we’d like
to know which plan you would prefer us to bill.
Which plan would you prefer billed? ___ Medical ___Vision
______________________________________________
Signature
____________________
Date
FINANCIAL POLICY
Patient Name:____________________________
Date:__________________
1) All co-pays are due at the time of service. We accept check, cash, and credit cards.
2) If a patient chooses to make monthly payments on account, we have a monthly payment
contract. If two consecutive payments are not made the account will go immediately to
collection.
3) If paid by check and the check is returned for non-sufficient funds, there will be a $25.00
service fee assessed to the account.
4) Any account sent to collection will be assessed a $30.00 collection service fee. An account
will be considered for collection after 60 days in arrears.
5) If your account has been sent to collection in the past, you will be responsible to pay the past
balance due before being seen. Also let it be known that if you have been sent to collection in
the past we reserve the right to collect payment for present services, at the time of service. We
will file your insurance and any monies paid by insurance will be refunded to you.
6) Always feel free to contact the office regarding your account. We will be happy to work with
you with a payment plan that will work for both of us. If you choose the monthly payment
arrangement, we will mail/fax our Payment Contract to you for signature and return to the office.
I have read and understand this financial policy.
SIGNATURE_______________________________________DATE________________
06/2014
Patient Name______________________________________Date_________________
Referred by:_______________
Past Optometrist: _____________________
Past Ophthalmologist: _________________
List Drug Allergies:
Major Medical Problems:
List Medications:
Surgery History:
Eye Injury/Disease/Surgery:
SOCIAL HISTORY: Smoking ____________
Alcohol Use____________
FAMILY HISTORY OF EYE DISEASE: Please indicate relationship to patient
Glaucoma:
Cataracts:
Diabetes:
Macular Degeneration:
Blindness:
Crossed/Lazy Eye:
Other:
REVIEW OF SYSTEMS: If no complaints, please circle REVIEWED and NEGATIVE
Ear/Nose/Throat
Gastrointestinal (bowels)
Genitourinary (bladder)
Cardiovascular
Respiratory
Musculoskeletal
Neurological
Hem/Endocrine (energy level)
Allergic/Immunity
Lymphatic
Integumentary (skin)
REVIEWED and NEGATIVE
Do you wear glasses? Y N
Do you currently wear contact lenses? Y N
Are you interested in contact lenses? Y N
PRACTICE PRIVACY STATEMENT
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION: PLEASE REVIEW IT
CAREFULLY
This is a formal notification, as required by the government concerning the privacy policy of this practice.
This practice has an obligation to maintain all medical information in the strictest of confidence. Our
practice cannot release information without your written request, including conversations, reminder calls,
test results, and other confidential issues. Patient information about health care is identified a “PHI” or
protected health information. This new policy requires that you, the patient, identify at the time of
registration with us specific information about the release of information. You can change this
information at any time with either written notification or verbal verification, followed up in writing.
Changes can only impact the care or information from that point forward.
Your protected health information (PHI) is a part of your medical care, and can be used or disclosed as
follows:
• For your treatment in this practice and other locations under our immediate care. this may include any
referral for services, diagnostic tests, or treatment related to your medical needs.
• For obtaining payment for treatment with your identified health care program. This would include any
documentation related to this care, including history forms, progress notes, or operative notes. This
would include eligibility verification, prior authorization, and claim submission.
• For operations of this practice, such as enrolling with insurance programs, hospital privileges,
accounting, and compliance with federal and state laws and regulations.
• Appointment reminders and health related benefit services only with your consent identified on the
registration form. This consent can be orally modified at any time, followed by written consent.
• Disclosure to your family and friends, concerning any health related information, with your consent
identified on the registration form. This consent can be orally modified at any time, followed by written
consent.
• Consent is not required for emergency care and treatment. An emergency is identified as a medical
condition than the judgment of the physician requires information for care on your behalf.
Your rights for your health information include: The right to request limits on the uses and disclosure at
registration or any time during your care. The right to choose how we send this information to you,
including an alternate address. The right to see and obtain copies of your PHI, but there may be copy
and postage fees. The right to get a listing of who we have made disclosures to about your PHI. The
right to correct your file through an amendment process if appropriate.
This practice reserves the right to modify or change this privacy statement at any time. Revision to this
notice will be available upon request by contacting the office. The changes will be effective retroactively
to the initial date of the privacy notice. An updated privacy notice will be posted in the office within 60
days of revision.
If you have a concern or complaint about how your protected health information is being used, you should
first contact our practice administrator to address your concerns. You also may contact the Office of Civil
Rights or the Ohio Medicare Carrier, CGS.
Office of Civil Rights - Regional Manager
Department of Health & Human Services
233 N. Michigan Avenue, Suite 240
Chicago, IL 60601
CGS
Part B Operations - HIPAA Compliance
PO Box 20018
Nashville, TN 37202