Date Patient name Patient# SSN. Male Female Birthdate Home phone Address City State Zip Check appropriate box: Minor Single Married Divorced Widowed Separated Patient's or parent's employer Work Phone Business address City State Zip Spouse or parent's name Employer Work phone If patient is a student, name of school or college City State Whom may we thank for referring you? Person to contact in case of emergency Phone
Name of person responsible for this account Relationship to patient Address Home phone Drivers License# Birthdate Financial institution Employer Work phone Is this person currently a patient in our office? Yes No
Name of insured Relationshiop to patient Birthdate Social Security Number Date employed Name of employer Work Phone Address of employer City State Zip Insurance company Group # Union or local # Insurance co. address City State Zip How much is your deductible? How much have you used? Max. annual benefit? Do you have any additional insurance? Yes No If yes, complete the following: Name of insured Relationship to patient Birthdate Social Security Number Date employed Name of employer Work Phone Address of employer City State Zip Insurance company Group # Union or local # Insurance co. address City State Zip How much is your deductible? How much have you used? Max. annual benefit?
I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me directly to the doctor. Signature of patient (or parent if minor) Date
Name: Date: Address City/State/Zip: Home Phone Work Phone Cell Phone Primary care Physidan's Name: Dr.'s Phone: PATIENTS MEDICAL HISTORY List any medications you are taking (including oral contraceptives, aspirin, over-the-counter medications and home remedies) Do you have any allergies to medications: Yes No If yes, please list: List all major injuries, surgeries andlor hospitalizations you have had: For Women: Are you pregnant and/or nursing? Yes No Have you had any of the following eye conditions?
Constitutional Fever, weight loss/gain Yes No Integumentary Skin Conditions Yes No Neurological Headaches Yes No Migraines Yes No Seizures Yes No Endoaine Thyroid/Other Glands Yes No Psychiatric Depression Yes No Anxiety Yes No Attention Deficit Yes No Bones/Joints/Muscles Rheumatoid Arthritis Yes No Other Arthritis Yes No Lymphatic/Hematologic Anemia Yes No Bleeding Problems Yes No Ears, Nose, Mouth, Throat Allergies/Hay Fever Yes No Sinus Congestion Yes No Runny Nose/Post Nasal Drip Yes No Chronic Cough Yes No Dry Throat/Mouth Yes No Respiratory Asthma Yes No Chronic Bronchitis Yes No Emphysema Yes No Vascular/Cardiovascular Diabetes Yes No Heart Condition Yes No High Blood Pressure Yes No Vascular Disease Yes No Gastrointestinal Diarrhea/Constipation Yes No Genitourinary Genitals/Kidney/Bladder Yes No Other, please list SOCIAL HISTORY This information is kept strictly confidential. However. you-may discuss this portion directly with the doctor If you prefer: YES, I would ptefer to discuss my Sodal History information diteetly with my doctor (check- box) Do you drive? Yes No If yes, do you haw visual difficulty When driving? Yes No Do you use tobacco products? Yes No If yes, type/amount/how long Do you drink alcohol? Yes No If yes, type/amount/how long Do you use illegal drugs? Yes No If yes, type/amount/how long Have you ever been exposed to or infected with: Gonorrhea Hepatitis HIV Syphilis
INSURANCE SIGNATURE ON FILE I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorized my doctor to act as my agent in helping me obtain payment of my insurance and/or Medicare benefits, and I request that payment of these benefits be made either to me or on my behalf to Anna M. Tones, O.D. for any services and materials furnished. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage (as indicated in Item 9 of the HCFA-1500 claim form or electronically submitted claim), my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as my agent, as above. Lifetime Patient Signature Date RELEASE OF EXAMINATION FINDINGS I authorize Dr. Torres to send a report of.rny examination to my physician, referring doctor and/or referring Health Professional Patient Signature Date I authorize Dr. Torres to discuss the results of my examination to the following individuals. (Please be sure to list spouse, parents, sons/daughters,. caregivers etc.)
Patient Signature Date RECEIPT OF PATIENT CONFIDENTIALITY POLICY I have received. Dr. Torres patient confidentiality policy Patient Signature Date
ANNA M. TORRES, O.D. 1420 N. Claremont Blvd., Ste. 209-B • Claremont, CA 91711 (909) 621-0057 • Fax: (909) 621-5485
We are pleased to assist you by filing the initial insurance claim with your insurance carrier. However, it is the patients/parents responsibility to provide all insurance information prior to services being rendered. Any changes in overage should also be provided prior to services rendered. Failure to do so will make it the patients/parents responsibility to collect from his/her own insurance carrier. It is our policy to allow 45 days for your carrier to pay the claim. If the claim has not been paid, payment from you will be expected. If you have not received an explanation of benefits from your carrier within 45 days, please contact them directly to determine why your claim has not been paid. The insurance is a contact between you, your employer or other group, and the insurance company. Coverage by the same company varies from one group to another so we cannot always determine your level of benefits in advance. Employers change their level of coverage and change plans so your coverage may have changed significantly since your last visit. The personnel office or insurance agent is your best source for current coverage. Insurance companies are also bought, sold, and merged. We may not often be informed of these changes until a claim is filed. All co-payments and/or material overages are due at the time of service. An authorization from your insurance company for services and/or materials does not constitute a guarantee of payment by the insurance company. All charges incurred are ultimately the patients/parents responsibility. We appreciate your assistance in helping you gain the greatest benefit from your insurance company. Remember that your coverage is a benefit and not an entitlement. I have read and understand the above terms. Account Responsible Digital Signature Date