Patient Responsibility Agreement

This is to inform you that your insurance carrier may cover procedures or diagnostic tests that your doctor consider necessary for the proper treatment of your medical condition. We agree to file the claims for you and assist in any appeal process necessary.

You understand that your Provider and/ or you may appeal any determination that a Benefit Agreement of Evidence of Coverage. You may have the right to Independent Medical Review through DMHC.

Your signature on this form acknowledges that you agree to bear full financial responsibility for all service provided if:

The Services are not covered by your insurance carrier, or
The Services have not been otherwise approved for payment.

Member Name

Signature of Patient

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

New Patient Questionnaire

Name

Today's Date

Age

Gender

Height

Date of Birth

Referring Physician

Telephone #

Primary Care Physician

Telephone #

Describe your present vision disorder or eye complaint

If you are using eye drops please list the name, dosage, and directions on how they are being used

Previous Eye Surgeries and/or Lasers (as much information)

General Medical Conditions

General Surgeries

Please list all medications you are currently taking along with the MG and directions on how it's taken (include over the counter and herbal medications)

Family History

Blindness

Yes

No

If yes, please specify relationship

Diabetes

Yes

No

If yes, please specify relationship

High Blood Pressure

Yes

No

If yes, please specify relationship

Macular Degeneration

Yes

No

If yes, please specify relationship

Glaucoma

Yes

No

If yes, please specify relationship

Do you have any of the following problems?

Allergies to medication?

Yes

No

If yes, please describe

Constitutional (fever, weight loss, other)

Yes

No

If yes, please describe

Ears/Nose/Mouth (hearing loss, sinus problems, sore throat, other)

Yes

No

If yes, please describe

Respiratory (asthma, shortness of breath, wheezing, coughing, other)

Yes

No

If yes, please describe

Gastrointestinal (heartburn, abdominal pain, diarrhea, vomiting, other)

Yes

No

If yes, please describe

Genitourinary (urinary problems, blood in the urine, other)

Yes

No

If yes, please describe

Integumentary (skin rashes, excessive dryness)

Yes

No

If yes, please describe

Musculoskeletal (muscle aches, joint pain, swollen joints, other)

Yes

No

If yes, please describe

Neurological (numbness, weakness, headaches, paralysis, other)

Yes

No

If yes, please describe

Hematologic/Lymphatic (blood disorder, leukemia, other)

Yes

No

If yes, please describe

Allergic/Immunologic (hay fever, allergies, other)

Yes

No

If yes, please describe

Endocrine (diabetes, thyroid problems)

Yes

No

If yes, please describe

If diabetic, what is the duration?

Cardiovascular (heart problems, chest pain, heart rate sore throat, other)

Yes

No

If yes, please describe

Psychiatric (depression, anxiety, other)

Yes

No

If yes, please describe

Social History

Occupation

Do you smoke or have you ever smoked?

Yes

No

If YES, how many years?

Years Quit

Do you drink alcohol?

Yes

No

If YES, how much?

Occasional

1 per day

2_3 per day

4+ per day

Additional Comments

Completed by

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

New Patient Demographics

Date

Drivers License # (list state if not CA)

Social Security #

Last Name

First Name

Middle Initial

Address

City

State

Zip Code

Date of Birth (MM/DD/YYYY)

Home Telephone

Mobile Telephone

Email

Marital Status

Single

Married

Divorced

Widowed

Domestic Partner

Gender

What is your preferred language?

Race/Ethnicity

Black/African American

Native/Hawaiian/Pacific Islander

American Indian/Alaska Native

Asian

White/Caucasian

Hispanic/Latino

Middle Eastern

Other

Who referred you?

Your Employer

Work Telephone

Work Address

City

State

Zip Code

Spouse's Name

Spouse's Employer

Who do we call incase of emergency?

Relationship

Telephone

Primary and Secondary Insurance Information

PLEASE PROVIDE A COPY OF ALL INSURANCE CARDS AND DRIVER’S LICENSE

I hereby authorize all insurance benefits to be paid directly to THE RETINA PARTNERS. I understand that I am responsible for charges as designated by my insurance companies (e.g., deductibles, co_payments, etc.) I am also responsible for all charges not covered by insurance and for any finance fees incurred on unpaid balances. I authorize THE RETINA PARTNERS to release any information to my insurance company when requested by them.

Signature (Insured and authorized)

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Notice to Our Patients

HIPAA:

Federal law passes 1996, The Health Insurance Portability and Accountability Act (HIPAA) mandates our office to notify you of our privacy practices effective as of April 14, 2003. The Purpose of this law is to protect the privacy and security of a person’s health information. Although these practices have always been our policy, it is required that each of our patients is informed and acknowledges receipt of this information.

After reviewing the “Notice of Privacy Practices” carefully, please sign and return this for our office.

Thank you for your cooperation in this matter.

If you have any questions, please contact our Practice Administrator:
(818) 788–9333 or by mail,
16500 Ventura Blvd.
Suite #250
Encino CA, 91436

I acknowledge that I have received a copy of the “Notice of Practice” from the office of The Retina Partners. I have read and understand the information contained in this document.

Signature of Patient or Guardian

Date

Print Name of Patient

Print Name of Guardian

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.