Patient Information Form



PATIENT INFORMATION/INFORMACION DEL PACIENTE



Please print/Por favor completar:

Date/Fecha SSN: DOB/Fecha de Nacimiento

Last Name Name / Apellidos Nombres

Address/Direccion: City/Ciudad:

State/Estado: Zip Code/Codigo Postal: Phone Number/Telf:

Email:

Sex/o: Status/Edo. Social: Race/Raza:
Language/Idioma:
Employer/Empleador: Phone/Telf
Business Address/Direccion Occupation/Ocupacion
Whom may we thank for referring you/ A quien debemos agradecer por su visita? Primary Doctor/Doctor Primario: In case of Emergency, who should we contact/ En caso de Emergencia a quien debemos contactar?:
Relationship/Parentesco: Phone/Telf



RELEASE OF FINANCIAL RESPONSIBILITY/ CONSENTIMIENTO FINANCIERO

of all insurance benefits otherwise payable to me for the services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Autorizo directamente el pago al Dr. de todos los beneficios ortogados por mi seguro. Entiendo que soy responsable de todos los cobros, pagados o no por mi seguro, y por todos los servicios recibidos por mi o mis dependientes. Autorizo al Dr. ya mencionado y/o acualquier proveedor de servicios en esta oficina de suministrar cualquier informacion requerida para asegurar el pago de mis beneficios. Autorizo el uso de mi firma para todo documento relacionado con mi seguro.


Signature of responsible party/ Firma del responsable: ___________________________ Date/Fecha: _______________________



NOTICE ABOUT NONDISCRIMINATION AND ACCESSIBILITY REQUIREMENTS



Appendix A to part 92- Sample Notice Information Individual about Non Discrimination and Accessibility Requirements and Sample Nondiscrimination Statement: Discrimination is Against the Law

South Florida Laser Eye Center, LLC complies with applicable Federal Civil Rights Laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. South Florida Laser Eye Center, LLC does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

South Florida Laser Eye Center, LLC:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

°
°


• Provides free language services to people whose primary language is not English, such as :

°
°


If you need these services, contact Cheryl Payne, Director of operations If you believe that South Florida Laser Eye Center, LLC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you may file a grievance with Cheryl Payne, Director of Operations at Eye Physician of Florida, LLP located at 13680 NW 5th St, Suite 240,Sunrise, FL 33325, Phone: 954.318.7370/ Fax: 954.318.7350 or email at: cpayne@eyefl.com You can file your grievance in person or by mail, fax or email. If you need help Cheryl is available to help you. You can also file a civil right complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1.800.368.1019, 1800.537.7697 (TDD)


REFRACTION OPTION



South Florida Laser Eye Center does not accept insurance as payment for the refraction (the test used to find your glasses prescription). We do offer the refraction at a discounted fee of $45.00. You are under no obligation to have the refraction performed at South Florida Laser Eye Center. The refraction might be a covered charge by your insurance at a different office. It would be your responsibility to determine this information.

As stated, your insurance may or may not pay for all of your healthcare costs. Some items and services are not considered “covered benefits” under your health insurance plan at certain offices, and as such, your insurance will not pay for these services at these offices. This form applies to Medicare and/or your health insurance advance beneficiary notice of non-coverage.

There are certain tests and/or procedures that help us make a better informed decision regarding your vision. These tests and/or procedures but come highly recommended by Dr. Hassan Tavakkoli. These tests and/or procedures are not covered by your health insurance at this office, but are an important part of your ocular care and it is recommended that you receive these services. Should you choose to receive these services; you will be personally responsible for the payment of such services. The purpose for this notice is to help you make an informed choice about whether or not you want to receive these services. Please note that any refraction is not a guarantee of results.



All Refrections area optional and are not mandatory



I acknowledge that I have been informed in advance of receiving these services, and have read this notice. I understand that the refraction test I have chosen is optional and not covered by my health insurance plan at this office. I have chosen to receive this service and understand that I will be financially responsible for the $45.00 charge indicated above.

I have chosen to:


Print Patient Name:

Patient Signature: _________________________________________________

DATE:




NOTICE OF PRIVACY PRACTICES ACKNOWLEDGMENT



Patient Name:

Date of Birth:
SSN:

By signing this form, you acknowledge that we have provided you with that we provided you with our Notice of Privacy Practices which explains how your health information may be handled various situations including your treatment, payment of your bills, and our healthcare operations. If your first date of service with us was due to an emergency, we must try to provide you with you with our Notice and get your written acknowledgement for the Notice as soon as we can once the emergency has passed.

[ ] I have received the Notice of Privacy Practices ( effective date
).

Patient's (or legal Representative's) Signature ___________________________ Date: Relationship of Legal Representative:

for office use only


To be completed only if acknowledgment is not signed.
1) Was the patient given a copy of the Notice of Privacy Practices?
2) Please explain why the patient was unable to sign this Acknowledgement and our efforts to try to obtain the patient's signature:


Name/Title ____________________________ Date _________________________

Place completed Acknowledgement in patient's medical record



Dear Patient:
Please read and sign this form as it concerns you, the patient.

Due to some changes in the insurance policies, it is no longer possible to interpret each individual policy. Although we try to update ourselves constantly, it is not always possible. Therefore, we urge you the patient to please check with your insurance company regarding your coverage and its limitation. Failure to comply with this suggestion could result in you being responsible for all cost incurred.

If you need a referral from your primary care doctor or your health insurance to be seen in this office, the referral must be present at the time of your visit or you need to reschedule. Our office is extremely busy and we cannot always get through the primary care physician office or insurance company to get authorization. We are often put on hold or told to call back another time. We welcome you to call your primary care physician and have your referral faxed to us.

If you have a co-payment or deductible, it must be paid at the time of service.


Patient or Guardian


Print Name


Date


NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT



I understand that under the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”). I have certain rights to the privacy regarding my protected health information. I understand that this information can and will be used to:

• Conduct, plan and direct treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
• Obtain payment from the third party payers.
• Conduct normal healthcare operations such as quality assessments and physicians certifications.

I have received, read and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient's Name
Relationship to Patient

Signature ____________________________________________

Date


I give my permission to discuss my medical condition with the following persons:

NAME: RELATIONSHIP:
NAME: RELATIONSHIP:
NAME: RELATIONSHIP:


Signature: _________________________ DATE:


Office use only


I attempted to obtain the patients signature in acknowledgement on this notice Privacy Practices Acknowledgement, but was unable to do so documented below:


Date: ________________________ Initials: ________________________ Reason: _______________________________________________________

RELEASE OF LIABILITY

I UNDERSTAND THAT MEDICATION IN THE FORM OF EYE DROPS WILL BE PLACED IN MY EYES DURING MY EXAMINATION. ONE OF THE DROPS IS AN ANESTHETIC; THE OTHERS ARE TO DIALATE MY EYES.

I UNDERSTAND THAT I CAN HAVE AN ALLERGIC REACTION TO THE DROPS.

I UNDERSTAND THAT HAVING MY PUPILS DIALATED WILL BLUR MY VISION AND MAKE MY EYES SENSITIVE TO LIGHT. THESE EFFECTS SHOULD LAST ONLY A FEW HOURS. DURING THE TIME THAT MY PUPILS ARE DIALATED DRIVING OR OPERATING MACHINERY (WHICH COULD CAUSE BODILY INJURY) SHOULD BE AVOIDED.

PATIENT OR GUARDIAN: WITNESS: DATE:




DECLARACION DE RESPONSABILIDAD

ENTIENDO QUE DURANTE EL EXAMEN DE OJOS, EL USO DE GOTAS MEDICINALES SERAN USADAS. UNA DE ESTAS GOTAS ES ANESTESIA Y LAS OTRAS SERAN PARA DILATAR LAS PUPILAS.

ENTIENDO, QUE UNA REACCION ALERGICA PUEDE OCURRIR.

TAMBIEN ENTIENDO QUE AL DILATARSE LAS PUPILAS, VERE BORROSO Y MIS OJOS ESTARAN SENSIBLES A LA LUZ. ESTOS EFECTOS DURARAN TAN SOLO UNAS HORAS. DURANTE ESTE TIEMPO MANEJAR U OPERAR CUALQUIER MAQUINA PUEDE CAUSAR LESIONES Y DEBE SER EVITADO.

PACIENTE O RESPONSABLE: TESTIGO: FECHA:








Date/Fecha Name/Nombre

Review of Systems:
Please indicate below your history of or current medical problems in the check box if a YES. If you have never had a problem leave blank.
Por favor indique su historial medico en las cajitas de abajo, marcando si tiene o ha tenido ese problema.


CONSTINTUIONAL






GENITOURINARY




HEAD, EYES, EARS, NOSE & THROAT





METABOLIC ENDOCRINE


RESPIRATORY





NEUROLOGICAL




PSYCHIATRIC



CARDIOVASCULAR





SKIN


GASTROINTESTINAL







MUSCULOSKELETAL


HEMATOLOGIC/LYMPHATIC


IMMUNOLOGIC






Other:


The mission of South Florida Laser Eye Center is to safeguard, preserve, and improve the vision of our patients. We have a patient centric approach to deliver exceptional eye care which is rooted in the personalized care, support and understanding we provide each patient.

We offer a full range of eye care services including cataract surgery, glaucoma treatment, medical and surgical retina and vitreous services including diabetes and macular degeneration, LASIK, corneal transplants, neuro ophthalmology, comprehensive eye exams, contact lens examinations including specialty lenses and fits, and a full service optical department.

Founded in 1994 by Dr. Hassan Tavakkoli, South Florida Laser Eye Center has helped thousands of patients see the world more clearly. We are dedicated to improving quality of life through sharper vision.
Location
8051 W Sunrise Blvd, Plantation, FL 33322, United States
  • (954) 474-2900
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