Established Patient Packet

Patient name 

Are you a resident of a nursing facility or hospice?  
Yes    No   

Do you have medical insurance?  
Yes    No   

Levenson Eye Associates uses an automated patient communication system. Examples of these communications include appointment reminders, reminders to schedule your next appointment and important announcements about our practice.

I authorize Levenson Eye Associates to contact me via an automated   phone   text   email system.  

This form does not apply to other physicians in connection with your ongoing care, insurance companies in connection with billing, state or federal healthcare agencies, or law enforcement agencies, and workers compensation agencies. We cannot release ANY of your medical information to any person or organization (including family members, spouse, etc.) unless you list their names below.

I give permission to the LEVENSON EYE ASSOCIATES to discuss the following medical and billing information about me (check all that apply):

Scheduling/Appointment Information  
Medical Information (including symptoms, diagnoses, medications, and treatment plan)  
Laboratory/Test Results  
Financial Details/Payment Information  
All the Above  
Other:

LEVENSON EYE ASSOCIATES has my permission to discuss the above information with:

Name  

Phone  

Relationship to patient  

I understand that I may revoke or terminate this permission at any time by submitting a written revocation to the LEVENSON EYE ASSOCIATES. I will contact LEVENSON EYE ASSOCIATES Privacy Contact in writing to terminate the authorization.

This authorization expires:  
No expiration date   
Date specified  unless revoked or terminated in writing by you or your patient personal representative.   
I decline permission to discuss medical information.

Balances
Your account must be current and prior balances paid before scheduling new appointments.

Missed Appointment Policy
Thank you for choosing us as your eye care provider. We understand that circumstances occasionally arise that do not allow you to keep your appointment but failing to arrive to your allotted appointment time without sending a cancellation notice AT LEAST 24 HOURS IN ADVANCE will cause a missed appointment may result in a fee of $35.00. This charge is not covered by your insurance. Multiple missed appointments may result in discontinued services.

Refraction Fee
The refraction process determines the prescription for your lenses and aids in the diagnosis and treatment of many eye diseases. Refraction does not include any screening or examination. Federal guidelines require that refraction must be billed separately for all patients. MEDICARE DOES NOT COVER REFRACTION. Since Medicare considers this a non-covered service, your supplemental insurance will deny payment as well. While some insurance plans may recognize and pay for refractions, most do not. Refraction is performed on almost all complete eye exams and payment will be expected at the time of service unless coverage and eligibility are verified. The refraction fee is $35.00.

Contact Lens Fitting Fees
A contact lens fitting determines if the contact lenses safely fit on your eyes and which lenses provide the best vision, comfort, and health for your eyes. The process includes the measurement of the eyes; the design and selection of lenses; and follow-up visits for up to eight weeks. After wearing contacts for a period, your doctor will require a re-examination at least once a year to verify that your contact lens prescription is still appropriate and healthy for your eyes. Most of the time, medical insurances do not pay for these services though some vision plans do provide partial coverage for contact lens services. Check with your insurance carrier to verify what coverage you have for contact lens services. Our fitting fees for disposable contact lenses range from $125.00 to $225.00, depending on specific needs/complicity. Renewal and refitting fees for disposable contact lenses range from $95.00 to $225.00. Contact lens fitting fees are due at the time of service. No contact lenses will be dispensed prior to the payment of these fees.

Are you allergic to any medications?  
Yes    No   

Do you use any illicit drugs?  
Yes    No   

Do you drink alcohol?  
Yes    No   

Do you use tobacco products?  
Yes    No   

Do you wear  
Glasses    Contact Lenses    Neither   

Please check any of the problems you have with your vision:  

Please check any of the problems you have with your eyes:  

Have you ever had any eye injury?  
Yes    No   

Have you ever had eye surgery?  
Yes    No   

Do you have any known eye diseases?  
Yes    No   

List any medications or eye drops you are currently taking (prescription and over-the-counter)

        

Add another medication?

Yes   No   General: (fever, chills, weight change, malaise, cancer)

Yes   No   Ears, nose, throat: (hard of hearing, nose bleeds, ear ache, cough, dry mouth, etc.)

Yes   No   Cardiovascular: (high B.P., chest pain, heart disease, etc.)

Yes   No   Respiratory: (short of breath, wheezing, etc.)

Yes   No   Gastrointestinal: (diarrhea, constipation, blood in stool, ulcers, stomach upset, loss of appetite, hepatitis, etc.)

Yes   No   Genital, kidney, bladder: (painful urination, frequent urination, blood in urine, jaundice, etc.)

Yes   No   Females: Are you pregnant? Nursing?

Yes   No   Muscles, bones, joints: (joint pain, arthritis, cramps, swelling, stiffness, etc.)

Yes   No   Skin: (rash, growths, etc.)

Yes   No   Neurological: (numbness, headache, seizure, stroke, etc.)

Yes   No   Psychiatric: (depression, anxiety, insomnia, etc.)

Yes   No   Endocrine: (diabetes, thyroid disease, excessive thirst, etc.)

Yes   No   Blood/lymph: (bleeding, high cholesterol, anemia, etc.)

Yes   No   Allergic/immunologic: (itching, hives, lupus, rheumatoid arthritis, HIV/AIDS, etc.)

Signature of Patient/Parent or Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.

 

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