Registration Forms (Online Version)

Mailing Address (DIRECCIỐN):

Emergency name/phone number where parents/guardians can be reached (EN CASO DE EMERGENCIA):

Pediatrician/Family Physician: (DOCTOR GENERAL)

Other physicians to receive a report:

STEP 2 : Insurance Information (Paso 2: Información sobre Seguros)

INSURANCE INFORMATION
Your claim can not be paid without the following information

ALL PATIENTS AND GUARANTORS:

Please read the following paragraphs and sign below :

FEDERAL STATUTES REQUIRE ALL PHYSICIANS WHO PARTICIPATE IN THE MEDICARE AND MEDICAID PROGRAMS TO COLLECT FROM PATIENTS REGARDLESS OF INSURANCE CARRIER, ANY OUTSTANDING BALANCES PAYABLE TO THE PHYSICIAN AS SET FORTH BY THEIR INSURANCE POLICIES. FURTHERMORE, ALL SERVICES MAY NOT BE COVERED UNDER YOUR INSURANCE POLICY. A “REFRACTION” IS REQUIRED TO PRESCRIBE GLASSES. IN CHILDREN, THIS SERVICE IS A MEDICALLY NECESSARY PART OF A COMPLETE EYE EXAM. IT IS MOST OFTEN NOT CONSIDERED PART OF MEDICAL CARE AND FALLS UNDER VISION OR ROUTINE EYE COVERAGE** AND MAY BE REFUSED BY YOUR MEDICAL INSURANCE POLICY. UNLESS VERIFIED BY THE INSURANCE COMPANY PRIOR TO YOUR OFFICE VISIT, THE REFRACTION FEE OF $55.00 IS PAYABLE AT THE TIME SERVICES ARE RENDERED. IN CHILDREN, IT IS USUALLY THE REASON FOR THE OFFICE REFERRAL.

‘*PLEASE NOTE: YOUR ROUTINE VISION PLAN COVERAGE IS OFTEN SEPARATE FROM YOUR MEDICAL INSURANCE PLAN, AND TWO INSURANCE COMPANIES CAN NOT BE BILLED FOR SERVICES ON THE SAME DAY.

DURING YOUR FIRST VISIT AND YOUR COMPLETE EXAMS, DILATING DROPS ARE USED TO ENLARGE THE PUPILS OF THE EYE TO ALLOW VISUALIZATION OF THE INSIDE OF YOUR EYES AND TO PERFORM REFRACTIONS IN PREVERBAL CHILDREN. DILATING DROPS BLUR VISION AND MAKE BRIGHT LIGHTS BOTHERSOME. DRIVING MAY BE DIFFICULT IMMEDIATELY AFTER THE EXAMINATION, IT’S BEST IF YOU MAKE ARRANGEMENTS NOT TO DRIVE YOURSELF. ADVERSE REACTIONS MAY BE TRIGGERED BY DILATION IN SUSCEPTIBLE INDIVIDUALS. THESE SIDE EFFECTS ARE EXTREMELY RARE AND CAN BE TREATED WITH IMMEDIATE ATTENTION. IN CHILDREN, DILATING DROPS MAY CAUSE FACIAL FLUSHING, SKIN RASH, OR INCREASED IRRITABILITY.

I AUTHORIZE PAYMENT TO THE DOCTOR FOR THE SURGICAL AND/OR MEDICAL BENEFITS PAYABLE UNDER THE TERMS OF MY INSURANCE. I ALSO UNDERSTAND AND AGREE THAT FULL PAYMENT FOR MEDICAL AND OPTICAL SERVICES PROVIDED IN THIS OFFICE FOR MYSELF AND/OR MY DEPENDENTS IS DUE AND PAYABLE AT THE TIME OF SERVICES UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE. I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR ALL DEDUCTIBLES, COPAYMENTS, CO-INSURANCES, AND NON-COVERED SERVICES (INCLUDING REFRACTIONS) NOT PAID BY MY INSURANCE COMPANY. IF A CHECK IS RETURNED, THERE WILL BE A $15 SERVICE CHARGE. THERE WILL BE A NON-CANCELLATION FEE OF $25.00 FOR APPOINTMENTS NOT CANCELLED 24 HOURS IN ADVANCE. ACCOUNTS DELINQUENT OVER 90 DAYS WILL BE AUTOMATICALLY REFERRED TO A COLLECTION AGENCY. IF MY ACCOUNT BECOMES DELINQUENT IN PAYMENT AND IS REFERRED TO A COLLECTION AGENCY OR AN ATTORNEY, I AGREE TO PAY ALL COSTS OF COLLECTIONS INCLUDING REASONABLE ATTORNEY’S FEES THAT MAY APPLY.

ASSIGNMENT OF BENIFITS: I HEREBY AUTHORIZE PAYMENT DIRECTLY TO GARIMA LAL, MD/PEDIATRIC EYE ASSOCIATES, INC. OF ANY AND ALL MEDICAL BENEFITS APPLICABLE AND OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE TO THE PEDIATRIC EYE ASSOCIATES FOR CHARGES NOT COVERED BY THIS ASSIGNMENT.

STEP 3: Medical History (Paso 3: Historia de la Medicina)

Patient’s Medical History with Review of Systems

HISTORY OF EYE PROBLEMS:

RECENT EYE SYMPTOMS:

Yes No IF YES, WHICH EYE?

FAMILY HISTORY: Do the patient’s relatives have any ofthe following?

Yes No IF YES, WHO?

At what age did your child’s birth parents begin wearing glasses?

SOCIAL HISTORY :

MEDICAL HISTORY AND REVIEW OF SYSTEMS:

Yes No IF YES, EXPLAIN BELOW

4. Birth history for patients 10 years old or younger:

Birth weight :

length of pregnancy if premature

STEP 4 : Consent Disclosure Medical Information

(Paso cuatro: Diseminación de Información Consentimiento médico)

, hereby allow and give consent for the following family members, friends, or health care surrogates to accompany me in the exam room during my visit or discuss my health information with the physician:

, autorizo a los siguientes familiars, amistades 0 personas a cargo de mi bienestar, a presenciar 0 discutir mi condición de salud durante mi visita 0 la visita de mi hijo/a con el medico:

May we leave a message on your answering machine, cell phone, or with the person that answers the phone?

Please, be sure you complete All SECTIONS Prior to submitting your registration.
Do Not submit form after each step.