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Logo_JPG_MIAMI EYE SPECIALIST

NEW PATIENT FORMS

Completing your new patient forms in anticipation of your appointment will
ensure a timely appointment and seamless process on the day of your visit
with our specialists. Please complete this packet prior to your visit.

Any questions prior to your visit, feel free to give us a call at 954-452-9922

PATIENT INFORMATION

PHARMACY AND REFERRALS

I am the above patient and attest this information is correct to the best of my knowledge.

PAST MEDICAL HISTORY (SELECT ALL THAT APPLY)

PAST SURGICAL HISTORY (SELECT ALL THAT APPLY)

OCULAR HISTORY (SELECT ALL THAT APPLY)

OCULAR SURGERY (SELECT ALL THAT APPLY)

MEDICATIONS

Please list all medications that you are currently taking including supplements:



















    ALLERGIES

    Please list all known allergies (environment, drug, food), as well as the type of reaction and level of severity:

    SMOKING STATUS

    ALCOHOL CONSUMPTION

    OTHER DETAILS

    DRIVING STATUS

    FAMILY HISTORY (SELECT ALL THAT APPLY)

    Do you have a living will?

    DILATION EYE DROPS

    Dilating drops are used to dilate or enlarge the pupils of the eye to allow the ophthalmologist to get a full view of the inside of the eye, the retina. Dilating drops frequently blurred vision for a length of time that varies from person to person and may make bright lights bothersome. It is not possible for your ophthalmologist to know how much your vision will be affected. Because driving may be difficult, you may want to make arrangements for a ride.

    RELEASE OF INFORMATION

    I here by authorize Miami Eye Specialists to release information acquired during my examination and treatment to my insurance company or patient’s employer for Workman’s Compensation.

    ACKNOWLEDGMENT

    I acknowledge that the privacy practices of this office are available upon my request. I attest that I have read and understand the Patient Registration form. All questions regarding this form have been answered.

    REFRACTION POLICY

    Refraction is a very important part of your eye exam. If you are experiencing blurred vision or a decrease in visual acuity on the eye chart, refractions are performed for the following reasons:
    <br Diagnostic Test: To determine the best possible visual acuity and function of your eyes and
    diagnose if there are any medical problems with your eyes.

    Prescription for Glasses: To determine whether you can be helped in any way by a new glasses
    prescription either before or after any eye surgery.

    Note: Medicare and most medical insurance plans DO NOT cover it. If you have a separate vision plan that covers refractions. The cost for refractions is $75. If you have any questions, please let us know.

    HIPAA RIGHT OF ACCESS FORM FOR FAMILY MEMBER/FRIEND

      I,, direct my health care and medical services providers and payers to disclose and

      release my protected health information described below to:




      Health Information to be disclosed upon the request of the person named above (Check either A or B)

      A. Disclose my complete health record (including but not limited to diagnoses, lab tests, prognosis, treatment, and billing, for all conditions)

      B. Disclose my health record, as above, BUT do not disclose the following (check as appropriate):

      Mental Health Records

      Communicable Diseases (Including HIV and AIDS)

      Alcohol/Drug Abuse Treatment

      Other (Please Specify):

      Form of Disclosure (unless another format is mutually agreed upon between my provider and designee):

      An electronic record or access through an online portal

      Hard copy

      This authorization shall be effective until (Check One):

      All past, present, and future periods

      OR Date or Event: unless I revoke it. (NOTE: You may revoke this authorization in writing at any time by notifying your
      health care providers, preferably in writing.)

      SIGNATURE ON FILE, ASSIGNMENT OF BENEFITS, FINANCIAL AGREEMENT

      1. MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Miami Eye Specialists for services furnished me by Miami Eye Specialists. 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 or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the CMS-1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Miami Eye Specialists accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare Carrier.

      2. MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the CMS1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Miami Eye Specialists, if possible or otherwise to me.

      3. RELEASE OF INFORMATION: Miami Eye Specialistsmay disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any person or corporation (1) which is or may be liable or under contract to Miami Eye Specialists for reimbursement for services rendered, and (2) any health care provider for continued patient care. Miami Eye Specialists may also disclose on an anonymous basis any information concerning my case, which is necessary or appropriate for the advancement of medical science, medical education, medical research, for the collection of statistical data or pursuant to State or Federal law, statute or regulation. A copy of this authorization may be used in place of the original.

      5. NON-COVERED SERVICES: I understand that Miami Eye Specialists contracts with health care service plans (i.e., HMOs, PPOs) relate only to items and services which are covered by the health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services, which are determined by the health care service plans not to be covered. Examples of non- covered services include, but are not limited to, services not specified as being covered in the patient’s contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient and treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with Miami Eye Specialists to obtain necessary health care service plan authorizations.

      6. FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Miami Eye Specialists, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Miami Eye Specialists for payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, is hereby assigned to Miami Eye Specialists. If copayments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Miami Eye Specialists. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill.

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