New Patient Information and Consent Form

Patient Name*

First NameMiddle NameLast NameSuffix

Preferred Name

Patient Gender*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

SSN*

Patient Birth Date*

MonthDayYear

Home Phone

Area CodePhone Number

Cell Phone

Area CodePhone Number

Email

How did you hear about our office?

Please check your preferred method of contact for appointment confirmation:

I prefer to receive promotions and updates via...

emailsnail mail

Health InsuranceWorkers CompAuto AccidentNone

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Area CodePhone Number

Claim Number

Date of Accident/Injury

Subscriber ID

Group Number

Health InsuranceWorkers CompAuto AccidentNone

Insurance Company Name

Insurance Company Address

Insurance Company Phone

Area CodePhone Number

Claim Number

Date of Accident/Injury

Subscriber ID

Group Number

Do you have a personal physician (PCP)?

YesNo

Physician's Name

Physician's Phone

Area CodePhone Number

Date of Last Visit

Do you have an ophthalmologist?

YesNo

Physician's Name

Physician's Phone

Area CodePhone Number

Date of Last Visit

Type of medical information to be disclosed:

All Medical RecordsOther

Allowed purpose of disclosure of information:

I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to AOP. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire 5 years from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about the disclosure of my health information, I can contact the authorized individual or organization making the disclosure.
I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

Which side is the afflicted eye?

LeftRightBoth

How did you lose/injure your eye(s)?

In 500 letters or less

Was your eye removed (enucleated) or eviscerated?

Yes, enucleatedYes, evisceratedNo, my eye is still there

Date of enucleation/evisceration surgery?

Doctor who performed the surgery?

Do you currently wear an artificial eye or scleral cover shell?

YesNo

How old is your current prosthesis?

Are you currently having any issues or concerns?

When was your last polish/cleaning?

How can we accommodate you better during your visit?

FINANCIAL POLICY We realize that every person’s financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the care you need with respect to your budget. Health Insurance At this time, Advanced Ocular Prosthetics Inc. accepts all Blue Cross/Blue Shield insurance plans as well as all UPMC Health Plans. You, the patient, are responsible for all deductible and co-insurance under your plan. If you have a different insurance plan you are responsible for the full amount of all services provided by Advanced Ocular Prosthetics Inc. We are happy to file the forms necessary to see that you receive the full benefits of your insurance coverage, however we cannot guarantee payment. Because the insurance policy is an agreement between you and the insurance company, we must emphasize that as a specialty provider our relationship is with you. Please know that we will do everything possible to see that you receive the full benefits of your policy but ultimately you, the patient are responsible for all charges. If your insurance company pays AOP, we will promptly refund any overpayment to the patient. Payment For your convenience, AOP accepts cash, check, Visa, MasterCard, Discover and Care Credit, which offers interest free payment plans. All payments, including deductible and co-insurance, are due the day of your appointment.*

AUTHORIZATION AND RELEASE I authorize AOP to release any information and/or records of my care to third party payers. I hereby assign AOP all insurance benefits, including major medical benefits, due in consideration of the ocular prosthetic and it’s care that I have received or will be receiving. I hereby authorize my insurance company(s) to pay benefits directly to AOP. I agree to be responsible for all charges not covered by my insurance. I also understand that failure to receive proper physician authorization may result in denial of benefits.*

MEDICAL RECORDS RELEASE I hereby authorize the use and/or disclosure of my protected health information as described above.*

CONSENT FOR TREATMENT I, the undersigned, hereby authorize the ocularist at Advanced Ocular Prosthetics Inc. to furnish such examination, fitting and outpatient care which in the physician’s judgment is recommended or necessary for the treatment of any illness or condition. *

PHOTOGRAPHY RELEASE We routinely take pictures of our patients. We do this in order to keep record of our patients and their prostheses. Sometimes we use these photos for lectures or presentations that are purely for educational purposes. By initialing here, you are stating that it is acceptable for us to use your photos for educational purposes. This includes promotional material and social media.*

Anything else we need to know?

Signature*

Insurance - Primary

Insurance - Secondary

Doctor Information

Medical Records Release Authorization

Medical History

Office Policies