* Patient Name (Last, First, Middle): (Required)
Date of Birth: *
Gender:
Social Security Number:
Ethnicity: Select an Option Hispanic or Latino not Hispanic or Latino Unknown Decline to answer
Race: Select an Option American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Other Race Decline to answer
If patient is a minor, lives with:
Relationship to patient (if patient is a minor):
Student Status: Select an Option Full time Part time Not a student
School Name:
School Address:
Spouse/Partner/Emergency Contact Information Marital Status: Select an Option Single Married Divorced Widowed Separated Minor Child
Spouse/Partner Name:
Spouse/Partner DOB:
Spouse/Partner Employer:
Spouse/Partner Employer Address:
Emergency Contact Name: *
Phone Number: *
Relationship to Patient:
Address if different from patient:
Patient or Parent/Legal Guardian Employment Status: Select an Option full time part time retired not employed
Employer Name:
Occupation:
Employer Address:
Responsible Party: if other than patient, please complete Responsible Party: Select an Option Guarantor Self
Responsible Party Name:
Relationship to Patient:
Check here if address is same as patient: Check here if address is same as patient Address:
Date of Birth:
Phone Number:
Employer Name:
Employer Address:
Referring Physician and Pharmacy Information Referring Physician:
Phone Number:
Primary Care Physician:
Phone Number:
Preferred Pharmacy Name:
Preferred Pharmacy Phone Number:
Medical Insurance Information Responsible Party: Select an Option Guarantor Self
Do you have medical insurance to cover your examination or treatment? * Note: If Yes, we will take a copy of your insurance card(s) when you arrive for your appointment.
Does your insurance company require a formal authorization or referral from a Primary Care Physician for our service? If yes, physician name:
Accident Information
Were you injured at work?
Is this covered by Workman's Compensation? Contact Person at Your Employer:
Please Describe:
Medical History
Check any that apply: Other Medical History:
Have you ever had a pneumonia shot?
Have you had a flu shot within the last 12 months? *
Have you been vaccinated against COVID-19? * Social History Smoking: Select an Option Smoker Ex-smoker Never Smoker
Alcohol: Select an Option None Occasional Social 1-2 Drinks/Day 3-4 Drinks/day
Your Occupation:
Living Condition: Select an Option Alone or With Spouse Nursing Home Family Other Caretaker
Do you use street drugs? If Yes, what and how long?
Have you ever had contact with a person who was exposed to or is infected with a sexually transmitted disease? If Yes, please explain:
Surgical History Please list all surgeries, including prior eye surgeries and the date of each:
Medications and Allergies Please list all medications, both prescribed and over-the-counter with the dosage and how often the medication is used:
Please list any medication, anesthesia, dye, or tape allergies and type of reaction you experience. If other, please explain:
Family History Responsible Party: Select an Option Guarantor Self
Please check any hereditary condition that an immediate family member has been diagnosed with If other, please explain here
Review of Systems
Ocular Symptoms and Diseases: Other Ocular Symptoms/Conditions Not Listed Above:
Please list any other symptoms and diseases, including date of onset:
Authorization Release of Information:
I authorize the release of any medical information necessary to my insurance company relative to services rendered. I further authorize the Payment of Benefits to the Physician for services rendered. I understand that this authorization remains valid unless/until I revoke it myself.
Financial Responsibility statement:
I acknowledge responsibility for payment of all medical fees regardless of insurance I may have to assist me in this responsibility. The only exception will be charges for services covered under a contractual agreement that has been entered into between my physician and an insurance company, or other third party payer. If for any reason my account should become delinquent, I am liable to pay all collection and legal fees.
Imaging Release:
I consent that images, including photographs, may be taken in connection with the medical services I receive. I understand that such images shall be retained in my medical record and may need to be shared with others, including but not limited to my insurance carrier. I also give permission for these images and information relative to them and/or relating to my case to be published and republished for the purposes of medical research, education or science. I realize any publication of these images will be "de-identified" so they cannot be recognized as belonging to me specifically. I understand that this release remains valid unless/until I revoke it myself.
During the course of your exam, it may be necessary to dilate your eyes with drops. In some people, the dilating drops cause blurred vision, light sensitivity, and inability to read. These problems go away as the effects of the drops wear off. You should be careful walking, going up and down stairs, and should not drive a car. In very rare cases, the drops may cause elevated eye pressure requiring further treatment. It is for this reason that we recommend someone come with you at the time of your exam as a driver. Also, for your comfort, you may obtain dark glasses or inserts for your glasses at the reception desk. By signing below, you certify that you have read and understand the statement regarding dilation and wish to proceed with the eye examination
I request the payment of appropriate, authorized Medicare benefits be made on my behalf to my physician/provider (checked above) for any services furnished to me by this physician/provider. Additionally, I authorize my medical provider to release any information about me to the Health Care Financing Administration, Centers for Medicare/Medicaid, and/or their agents that might be needed to determine any benefits payable for the services furnished. I will also permit a copy of this authorization to be used in place of the original.
I request the payment of appropriate, authorized benefits be made on my behalf to my physician/provider (checked above) for any services furnished to me by this physician/provider. Additionally, I authorize my medical provider to release any information about me to the insurance carrier and/or third party medical claims administrator, covering my at the time medical services are provided, that might be needed to determine any benefits payable for the services furnished. I will also permit a copy of this authorization to be used in place of the original.
Patient Signature
Dear Patient,This portion is OPTIONAL. It is to be used in the event that either the patient, or the treating physician, has a specific desire or need to release all or any portion of a patient's protected health information (a/k/a PHI)/medical record to any persons or organizations not already involved with the patient's care. This form is included with a new patient's paperwork in order to provide an opportunity for a patient to provide authorization for the Midwest Eye treating physician to share their PHI to a guardian; other family members; non-referring physician(s); and/or other parties. If you do not wish to have any of your medical information shared with anyone other than the physician that referred you to Midwest Eye Institute, YOU DO NOT NEED TO COMPLETE THIS SECTION
Name
Relationship
Name
Relationship
Name:
Relationship
Limitations to this Authorization must be identified below. If this portion of the form is left blank, it is assumed that the information authorized for released is unrestricted. Please describe below any restrictions you wish to place on this authorization. (Restrictions might include limitations as to type of information released; specific dates or period of time involved; or a specific purpose for which the release might apply.)
Limitations
I may see and copy the information described on this form if I ask for it, and I can receive a copy of this form after I sign it if I request one. If my physician has initiated this Authorization, I understand that in most cases I will be treated regardless of whether I sign this authorization. However, if the purpose of the Authorization is to allow research-related treatment, I understand I may not be able to get that treatment without signing this form.I hereby authorize the release / use / disclosure of my individually identifiable health information (a/k/a Protected Health Information of PHI) as described above. I understand that this authorization is voluntary. I also understand that if the person or organization authorized to receive the information is not a health plan, health care provider, or contracted business associate of this practice or Midwest Eye Institute, the released information may no longer be protected by federal privacy regulations.
Patient Signature
Patient can set an expiration date for this Authorization in this space. Please list the expiration date below or on the occurrence of the following event:
Expiration Date (Optional) Or Event:
REVOCATION (optional): This authorization may be revoked at any time by notifying your Midwest Eye Physician in writing at: Dr. __________________________ C/O Midwest Eye Institute10300 N. Illinois Street, Suite 1000 Indianapolis, IN 46290If I, as a patient or patient representative, do revoke this authorization, I understand that action will not apply to activity that occurs before the Revocation is received.
As our patient, we are offering you a copy of Midwest Eye Institute's Notice of Privacy Practices to retain for your information/reference. Copies are available on our website under patient forms, and also can be obtained at any time from our reception desk or directly from the doctor's office. If you have any comments, questions, or complaints concerning our privacy practices, you may also contact the Secretary of the Department of Health and Human Services at: Secretary of the Department of HHS 200 Independence Avenue S.W. Room 509F, HHH Building Washington, D.C. 20201 Email: ocrmail@hhs.gov You will not be retaliated against or penalized by us for making an inquiry or filing a complaint. To obtain more information concerning this notice, you may contact our Privacy Officer: Song Hua-Lonberger Executive Director Midwest Eye Institute, P.C. 10300 N. Illinois Street, Suite 1000 Carmel, IN 46290 Attn: Patient Privacy Request Your signature is required below indicating that the entirety of the Midwest Eye Institute Privacy Practices policy has been shared with you. By signing you also acknowledge that an actual copy of this entire policy can be obtained in various locations.
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