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:

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

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New Patient Questionnaire

Family History

Blindness
Diabetes
High Blood Pressure
Macular Degeneration
Glaucoma

Do you have any of the following problems?

Allergies to medication?
Constitutional (fever, weight loss, other)
Ears/Nose/Mouth (hearing loss, sinus problems, sore throat, other)
Respiratory (asthma, shortness of breath, wheezing, coughing, other)
Gastrointestinal (heartburn, abdominal pain, diarrhea, vomiting, other)
Genitourinary (urinary problems, blood in the urine, other)
Integumentary (skin rashes, excessive dryness)
Musculoskeletal (muscle aches, joint pain, swollen joints, other)
Neurological (numbness, weakness, headaches, paralysis, other)
Hematologic/Lymphatic (blood disorder, leukemia, other)
Allergic/Immunologic (hay fever, allergies, other)
Endocrine (diabetes, thyroid problems)
Cardiovascular (heart problems, chest pain, heart rate sore throat, other)
Psychiatric (depression, anxiety, other)

Social History

Do you smoke or have you ever smoked?
Do you drink alcohol?
If YES, how much?
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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.

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New Patient Demographics

Marital Status
Race/Ethnicity

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.

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.

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Notice to Our Patients

HIPPA:

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.

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.

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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.

Close