Patient History Form Patient Name* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Gender* Male Female Social Security NumberHome PhoneWork PhoneCell PhoneEmail Insurance Provider*Insurance Identification Number*Insured's Name*Insured's Date of Birth*Mother's Name(if minor) First Last Father's Name(if minor) First Last Who may we thank for referring you?Emergency Contact Name*Emergency Contact Phone*Insurance Authorization and Assignment: I request that payment of authorized Medicare or other insurance company made either to me or on my behalf to Capital Eye Care for any services furnished by that party. I authorize any holder of medical or other information about me to release to the social security administration or it's intermediaries or carrier of any other insurance company any information needed for this or a related Medicare/other insurance claim. I understand my signature requests that payment be made and authorize release of medical information necessary to pay the claim. The physician or supplier agrees to accept the determination of Medicare as the full charge, and the patient is responsible only for the deductible, co-insurance and non-covered services. Co-insurance and the deductible are based upon the charge determination of Medicare.Signature*Date* MM slash DD slash YYYY Medical HistoryTo help our office better serve your specific needs, please check all that apply.Eye History Blurred Distance Vision Foreign Body Sensation Floaters or Spots Blurred Near Vision Mucous Discharge Flashes of Light Loss of Side Vision Dryness Cataract Blurred Night Vision Burning Macular Degeneration Double Vision Redness Glaucoma Fluctuating Vision Watery Eyes Retinal Detachment Halos Itchy Eyes Diabetic Retinopathy Headaches Tired Eyes Color Blindness Light Sensitivity Eye Pain or Soreness Lasik If Lasik, what year?General Health Conditions Ears, Nose, Throat Cardiovascular Disease Respiratory Joint Pain Thyroid Disease Asthma Diabetes Stroke Use Tobacco Products Hypertension HIV/AIDS Cancer Gastrointestinal Pregnant or Nursing Skin Neurological Other If Cancer, what type?If Skin, please specify:If Other, please specify:HeightWeightFamily History Diabetes Stroke Retinal Detachment Hypertension Macular Degeneration Cataract Cancer Glaucoma If Cancer, what type?Please list current medications: Medication allergies: Note: Most Insurance policies only pay a portion of your total charges. If you have any questions about your coverage, please contact your representative. We do not guarantee the accuracy of benefit information given to us by insurance companies. Please understand that financial responsibility for your account is yours and not the responsibility of your insurance company. I authorize the release of any medical of other information necessary to process insurance claims. I authorize payment of medical or vision benefits either to the physician or supplier of services rendered or to myself if the provider does not accept assignment. I understand that I am responsible for any balance my insurance does not pay.Patient Name* First Last Date of Birth* MM slash DD slash YYYY Signature*Date* MM slash DD slash YYYY HIPAA Acknowledgment & Privacy Practices SignatureDate MM slash DD slash YYYY Δ
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