Focal Point Vision Medical Questionnaire

Patient: DOB:

SOCIAL HISTORY- Please check all that apply

Alcohol Use: Yes ☐ No ☐ Tobacco Use: Yes ☐ No ☐ Able to read English Yes ☐ No ☐ Drives vehicle motor Yes ☐ No ☐

PAST OCULAR HISTORY-Please check all that apply

Cataracts Yes ☐ No ☐ Dry Eyes Yes ☐ No ☐ Amblyopia (Lazy Eye) Yes ☐ No ☐

Glaucoma Yes ☐ No ☐ Retinal Detachment Yes ☐ No ☐ Astigmatism Yes ☐ No ☐

Diabetic Retinopathy Yes ☐ No ☐ Macular Degeneration Yes ☐ No ☐ Myopia (Near sighted) Yes ☐ No ☐

Keratoconus Yes ☐ No ☐ Floaters Yes ☐ No ☐ Hyperopia (Far sighted)

Floaters Yes ☐ No ☐ Eye Infections Yes ☐ No ☐ Any Other:______________

Eye Injuries Yes ☐ No ☐ Corneal Ulcers Yes ☐ No ☐

OCULAR SURGERIES/PROCEDURES-Please check all that apply

Cataract Surgery Yes ☐ No ☐ Retinal Laser Surgery Yes ☐ No ☐ Lasik/PRK/RK Yes ☐ No ☐

Corneal Transplant Yes ☐ No ☐ Glaucoma Surgery Yes ☐ No ☐ Any Other: ___________ Yes ☐ No ☐

FAMILY HISTORY- Please check all that apply

Blindness Yes ☐ No ☐ Diabetes Yes ☐ No ☐ Fuch's Dystrophy Yes ☐ No ☐

Cancer Yes ☐ No ☐ Glaucoma Yes ☐ No ☐ Retinal Detachment Yes ☐ No ☐

Cataracts Yes ☐ No ☐ Macular Degeneration Yes ☐ No ☐ Corneal Transplant Yes ☐ No ☐

Please check if you CURRENTLY HAVE OR HAD any of the following

Arthritis/Joint problems Yes ☐ No☐ Fever Yes ☐ No☐ Prostrate Problems Yes ☐ No☐

Asthma Yes ☐ No☐ Gastritis/Reflux Yes ☐ No☐ Psychiatric problems/Depression Yes ☐ No☐

Bleeding Disorder Yes ☐ No☐ Gout Yes ☐ No☐ Sinus Problems/Allergies Yes ☐ No☐

Bronchitis/COPD/ Emphysema

Yes ☐ No☐ Heart Disease/Attack Yes ☐ No☐ Stroke or Neurological problems Yes ☐ No☐

Chronic Headaches/ Migraines

Yes ☐ No☐ Herpes Simplex Yes ☐ No☐ Thyroid Disease Yes ☐ No☐

Chest Pain/Discomfort Yes ☐ No☐ High Blood Pressure Yes ☐ No☐ Tuberculosis Yes ☐ No☐

Disabilities Yes ☐ No☐ High Cholesterol Yes ☐ No☐ Ulcers Yes ☐ No☐

Diabetes Type: 1 2 Insulin dependent? Yes No

Yes ☐ No☐ HIV Yes ☐ No☐ Unexplained Weight loss/gain Yes ☐ No☐

Dialysis Yes ☐ No☐ Jaundice/Hepatitis

Yes ☐ No☐ Other:_______________ Yes ☐ No☐

Excessive Bleeding with surgery

Yes ☐ No☐ Kidney /Renal Problem Yes ☐ No☐

Primary Care Physician: ________________________________________________________________

Referring Eye Care Provider: ________________________________________________________________

Form Completed by: ____________________________________ Relationship: ________________________

PATIENT SIGNATURE: __________________________________________ DATE:

REVISED 10-01-2015

FOCAL POINT VISION

MEDICATION LIST

Patient Name: ______________________________________________________ DOB: ______/______/__________

Please list all medications, vitamins or supplements that you are currently taking.

DRUG NAME: DOSAGE: PER:

PHARMACY INFORMATION

Pharmacy Name: ____________________________________________ ( ) Local ( ) Mail Order

Address: ________________________________________ City/State/Zip: ________________________

Phone: (_____)______________________________ Fax: (_____)______________________________

DRUG ALLERGIES

DRUG NAME: REACTION:

Date: _____________________

Have you EVER used: Flomax (tamulison) Avodart (dutasteride) Alfuzsin(uroxatral) Proscar (finasteride)

Circle YES Only

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health

care professionals for the purpose of evaluating your health, diagnosing medical conditions, and

providing treatment. For example, results of laboratory test and procedures will be available in

your medical record to all health professionals who may provide treatment or who may be

consulted by staff members.

Payment. Your health information may be used to seek payment from your health plan, from

other sources of coverage such as an automobile insurer, or from credit card companies that you

may use to pay for services. For example, your health plan may request and receive information

on dates of service, the services provided, and the medical condition being treated.

Health care operations. Your health information may be used as necessary to support the day-

to-day activities and management of Snip and Ference, P.A./Focal Point Vision Correction.

For example, information on the services you received may be used to support budgeting and

financial reporting, and activities to evaluate and promote quality.

Law enforcement. Your health information may be disclosed to law enforcement agencies to

support government audits and inspections, to facilitate law-enforcement investigations, and to

facilitate law-enforcement investigations, and to comply with government mandated reporting.

Public health reporting. Your health information may be disclosed to public health agencies as

required by law. For example, we are required to report certain communicable diseases to the

state’s public health department.

Other uses and disclosures require your authorization. Disclosure of your health information

or its use for any purpose other than those listed above requires your specific written

authorization. If you change your mind after authorizing a use or disclosure of your information

you may submit a written revocation of the authorization. However, your decision to revoke the

authorization will not affect or undo any use or disclosure of information that occurred before

you notified us of your decision to revoke your authorization.

Additional Uses of Information

Appointment reminders. Your health information will be used by our staff to send you

appointment reminders.

Individual Rights

You have certain rights under the federal privacy standards. These include:

- The right to request restrictions on the use and disclosure of your protected health

information

- The right to receive confidential communications concerning your medical condition and

treatment

- The right to inspect and copy your protected health information

- The right to amend or submit corrections to your protected health information

- The right to receive an accounting of how and to whom your protected health information

has been disclosed

- The right to receive a printed copy of this notice

Snip and Ference, P.A./Focal Point Vision Correction Duties

We are required by law to maintain the privacy of your protected health information and to

provide you with this notice of privacy practices.

We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices

As permitted by law, we reserve the right to amend or modify our privacy policies and practices.

These changes in our policies and practices may be required by changes in federal and state laws

and regulations. Upon request, we will provide you with the most recently revised notice on any

office visit. The revised policies and practices will be applied to all protected health information

we maintain.

Request to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As

permitted by federal regulation, we require that requests to inspect or copy protected health

information be submitted in writing. You may obtain a form to request access to your records by

contacting the receptionist or Privacy Official. Your request will be reviewed and will generally

be approved unless there are legal or medical reasons to deny the request.

Complaints

If you would like to submit a comment or complaint about our privacy practices, you can do so

by sending a letter outlining your concerns to:

Privacy Official

Snip and Ference, P.A./Focal Point Vision Correction

4775 Hamilton Wolfe, Bldg. 2

San Antonio, TX 78229

If you believe that your privacy rights have been violated, you should call the matter to our

attention by sending a letter describing the cause of your concern to the same address.

You will not be penalized or otherwise retaliated against for filing a complaint.

Contact Person

The name and address of the person you can contact for further information concerning our

privacy practices is:

Privacy Official

Snip and Ference, P.A./Focal Point Vision Correction

4775 Hamilton Wolfe, Bldg. 2

San Antonio, TX 78229

(210)614-3600

Effective Date

This notice is effective on or after April 14, 2003.

Focal Point Vision Financial Policy

Thank you for choosing Focal Point Vision as your healthcare provider. We are committed to providing you the best available medical care. Our personnel will be pleased to discuss our fees and this policy with you at any time. We ask that all patients read and sign our financial policy as well as complete our Patient Information form prior to seeing the physician. Payments for services are due at the time services are rendered. We accept cash, check, VISA, MasterCard and Discover. In special instances, we may accept assignment of insurance benefits. However, you must understand that:

1) Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract. Our relationship is with you. We cannot become involved in disputes between you and your insurer regarding deductible, co-payments, covered charges, secondary insurance and “usual and customary charges”.

2) All charges are your responsibility whether the insurance company pays or does not pay. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover.

3) Fees for these services, along with unpaid deductibles and co-payments are due at the time of treatment/service.

4) If your insurance company does not pay your claim within 30 days, it is your responsibility to contact your insurer to expedite payment. After all, if your insurance does not pay, you are responsible for payment.

5) If your insurance company does not pay in full within 45 days, we require that you pay the balance by cash, check, VISA, MasterCard or Discover.

6) Returned checks and balances older than 45 days may be subject to collection placement and all associated fees.

Please note: All appointment cancellations and reschedules must be made at least 24 hours in advance. Again, thank you for choosing Focal Point Vision as your healthcare provider. We appreciate your trust in us and we appreciate the opportunity to serve you. ______________________________________________ _____________________________ PATIENT SIGNATURE DATE

INFORMED CONSENT (Please check which applies)

___ I (DO) ___ (DO NOT) authorize Focal Point Vision to leave a message with any available person at my

home phone number, answering machine or with the emergency contact person I have listed. ___ I (DO) ___ (DO NOT) authorize Focal Point Vision to leave a message at my place of employment. I understand that if I schedule surgery, other people may hear my name, medical history, insurance benefits and financial liability. In the scheduling process the staff will: 1) Identify me by Name, 2) Discuss the details of my procedure, 3) Discussion of insurance benefits and financial liabilities will occur. I have been provided with a copy of the Focal Point Vision Privacy Practices. _____________________________________________ ____________________________ PATIENT SIGNATURE DATE

PATIENT INFORMATION NEW PATIENT-PLEASE PRINT

CHART #: Date: ___________________

Last Name: First Name:

Home Address: City: State: Zip Code:

SSN : DOB:

Gender: Marital Status: ☐ Married ☐ Single ☐ Divorced ☐ Widow

Home Phone: Cell phone:

Employer Occupation:

Work Phone:

Emergency Contact (other than spouse) Phone Number:

Preference of appointment reminder: ☐ Phone ☐ Text ☐ Email

Email Address: ____________________________________________________________________________

Please indicate how our heard about us: ☐ Internet: www. _________________________ ☐ Dr. _______________________ ☐ Friend ☐Newspaper ☐ Yellow Pages ☐ Other

RESPONSIBLE PARTY

Are you, the patient, and the responsible party for this account? ☐ Yes ☐ No

**If someone other than the patient is responsible for this account please provide their information.

Last Name: First Name:

Street Address:

City: State: Zip:

Home Phone: Work Phone: Cell Phone:

**PRIMARY INSURANCE INFORMATION**

Primary Insurance:

ID Number: Group Number:

Subscriber:

Insured's Date of Birth: Relation to Insured:

Employer Work Phone:

Address:

**SECONDARY INSURANCE INFORMATION**

Secondary Insurance:

ID Number: Group Number:

Subscriber:

Insured's Date of Birth: Relation to Insured:

Employer: Phone Number:

Address:

I hereby authorize my insurance company to pay directly to Focal Point Vision Correction, all benefits otherwise payable to me under the provisions of my policy. I hereby authorize the necessary medical information to be released to the insurance company for processing this claim and to be released to physicians or optometrists in connection with the continuity of care of patient. Photostat copies of this authorization will be considered as valid as the original. Patient Signature: _________________________________________ Today's Date: _____________________ Revised 09/04/2013

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Notice to Patient; We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish. ____________________________________________________________________________________ I acknowledge that I have received a copy of this office's Notice of Privacy Practices. __________________________________________________________________________________________ Please print your name here __________________________________________________________________________________________ Signature ______________________________________________________ Date We cannot discuss your protected health information (PHI) with anyone other than yourself unless you authorize us to do so. Please list below names(s) of the individual(s) you authorize our office to discuss care with. Your PHI maybe disclosed to the individual(s) listed below until you notify us otherwise in writing. _________________________________ __________________________________ _________________________________ __________________________________

FOR OFFICE USE ONLY

We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because: The patient refused to sign. Due to an emergency situation it was not possible to obtain an acknowledgement. We weren't able to communicate with the patient. Other (Please provide specific details) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ ____________________________ ___________________________ Employee signature Date

HIPAA Acknowledgement of Receipt of the Notice of Privacy Practices 2014

This form does not constitute legal advice and covers only federal, not state, law.

FOCAL POINT VISION

Services Not Covered by Health Insurance & Medicare

To All Our Patients:

The ONLY way to determine whether a patient's reduced vision is a matter of a simple

eyeglass adjustment or some other condition is to perform a REFRACTION. This is the

familiar "better one or better two?" part of the eye examination and it is critical in helping us

to determine your eyeglass prescription.

The rest of the eye exam, THE MEDICAL EXAM, determines if your eye is healthy or if there

are other disorders or conditions that are causing difficulties.

Why I am being charged a refraction fee?

Medicare and other health insurers will NOT pay for this vital part of the eye exam and will

ONLY reimburse for the medical eye exam component. The refraction component is the patient's responsibility.

ACKOWLEDGEMENT

I have read the above information and I understand that the refraction is a non-covered

service by my health insurance.

If I choose to have the Doctor perform a refraction and provide me with an eyeglass

prescription I accept full financial responsibility for the cost of this service. Co-pays and

deductibles are separate and not included in the refraction fee of $50.00. The fee will be

collected at the time services are rendered.

___________________________________ ______________________ Patient Signature Date

Revised 09-25-15