Patient Demographics
First, Middle and Last Name
Mailing Address
City, State, Zip Code
Employer Name, Address, Phone Number
Person Responsible for Account
Emergency Contact Name and Phone Number
How Were You Referred To Us
Insurance Information
Do you have medical insurance? If yes, Please present your Insurance ID cards to the front desk.
Insurance Company Name, Address & Phone Number
Name of Primary Insured
DOB of Primary Insured
Insurance Group #
Primary Ins. ID #
Patient History:
Preferred Language:
Primary Care Physician
Referring Physician
Health History
What is the main reason for your exam today?
When was your last eye exam?
When was your last medical exam?
Please list ALL of you Medical problems/conditions:
Please list ALL of your prior EYE surgeries, lasers and injections. Include date and Surgeon Name
Please list ALL of your OTHER past surgical Procedures. Include date and Surgeon name.
Please list name, dose and frequency of CURRENT medications you are taking. If none put "none".
Please list name, dose, which eye and frequency of any CURRENT eye drops you are taking. If none put "none".
Please list ALL of your known Drug allergies and your reaction to them. If none put "none".
Review of Symptons
Are you currently experiencing or do you have any of the following medical problems?
Please elaborate on any of the above that you marked.
Please elaborate.
Family History
Do any of the following eye/medical conditions run in your family? if "yes" please fill in how related to you (ex: parent, sibling, aunt/uncle or grandparent.
Eye Diseases:
Lazy Eye
Glaucoma Suspect
Macular Degeneration
Retinal Detachment
Crossed Eyes
Other Eye Conditions
Systemic Diseases:
Heart Disease
High Blood Pressure
Thyroid Disease
Please Explain Other Condition
If no to all in Family History please mark here.
Social History
Current Occupation
Do you drink alcohol?
Do you Smoke?
Refraction Policy Disclosure
Refraction is the process of determining the eye?s refractive error, or need for corrective spectacles. It is an essential part of an eye examination, but it is NOT a covered service by Medicare or most insurance. Our office fee for a refraction is $55.00 and this fee is collected in addition to the patient?s co-pay the day the service is performed.<br/><br/><br/>ACKNOWLEDGMENT<br/><br/>I have read the above information and understand that the refraction is a non-covered service. I accept full financial responsibility for the cost of this service. The co-pay is separate from, and not included in, the refraction fee.
Financial Policy
Eye Care Associates of Denton has a responsibility to provide quality healthcare services to patients. In the interest of maintaining a good doctor-patient relationship and continuing the delivery of quality healthcare, it is our hope that you will take responsibility for your financial obligation to our practice. The following are general policies we have established for our patients, which we believe allow the flexibility that some patients need. We encourage you to discuss your account, and any payment arrangements that you desire, with our office personnel. Discussion of these issues early on in your treatment process will prevent most concerns and issues.
INSURANCE: As a courtesy to our patients, we will file claims on all visits and procedures, whether they are delivered in our office or the surgery center. When we file a claim on your behalf, it is with the understanding that benefits will be assigned to Eye Care Associates of Denton, Dr. Nadeem Haq (that is, the insurance company will pay Eye Care Associates of Denton, Dr. Haq directly). You are responsible for payment of all deductibles, co-insurance and non-covered services. If, after 90 days the claim remains unpaid then the balance for that claim will be released to the patient?s/guarantor?s responsibility. Please remember insurance coverage is a contract between the patient and the insurance company. The ultimate responsibility for understanding your insurance benefits and for payment to your doctor rests with you.
REFERRALS: You are required to 1) know whether or not your insurance requires a referral and 2) obtain that referral before you are scheduled to see Dr. Haq. You should take the time to call your insurance company to ask specifically about the doctor you wish to see and your covered benefits. Referrals typically have an expiration date and a limited number of visits so you should be careful to monitor the dates and visits. It is the patient?s responsibility to obtain his or her referral before the scheduled appointment and bring it with them to the appointment. Our office will not see a patient who does not have a valid referral.
NO INSURANCE: Patients who do not have insurance are expected to pay for all services rendered at the time of service. We will request payment for outpatient procedures in advance of having the procedure performed. We understand that individual situations may make it difficult to meet these financial expectations and we are happy to discuss other payment arrangements as needed.
NO SHOW POLICY: Patients who do not show for their office visit will be charged a $50.00 fee. If you do not show for a procedure there will be a $250.00 fee. These will be charged to your account.
Poliza por no llegar: Habra un cargo agregado a su cuenta de $50.00 por no llegar a su cita al consultorio, y de $250.00 por no llegar al procedimiento.
RETURNED CHECKS: Your account will be charged a $30.00 fee for each returned check. In addition, you will be asked to bring cash or a money order to our office to cover the returned check and fee.
PAST DUE ACCOUNTS: Patients who have not made an effort to make payment arrangements or have not expressed an interest in meeting their financial obligation to us may be turned over to a collection agency. Patients who have allowed their account to be turned over to an agency will be expected to satisfy their financial obligation to us, and to pay for any future services in advance, before being seen by the physician.
NON-COVERED SERVICES: You have scheduled a visit with the physician that your primary care physician or referring physician believes to be relevant to evaluate, monitor and protect your health. However, Medicare and certain other insurance companies will only pay for services that they determine to be ?reasonable and necessary?. If Medicare or another insurance company determines that your visit with the physician is not ?reasonable and necessary?, they will deny payment for that service. Sometimes insurance companies will not cover an office visit when the patient comes to the doctor with no symptoms and is requesting a screening procedure. Denial of payments by your insurance company does not mean that you do not need the visit with your physician. Neither Medicare nor other insurance companies cover all services. In the event your insurance plan determines a service to be ?not covered? you will be responsible for the complete charge. Payment is due upon receipt of statement from our office.
REFRACTION SERVICE AND FEE: Note that medical insurance plans, including Medicare, do NOT cover refractions or routine eye examinations. Refraction is the process of determining if there is a need for corrective eyeglasses. It is an essential part of an eye exam and necessary to in order to write a prescription for glasses. Our office fee for refraction is $55.00 and this fee is collected at the time of the service in addition to any co-payment your plan may require.
PROCEDURES: Payment will be expected at the time you schedule your procedure. It is our policy to collect a deposit prior to your procedure. This includes deductibles, co-insurances or co-pays. Payment arrangements need to be discussed with our office staff in advance. Any refunds that need to be issued will be done so by check. No chargeback?s on credit cards will be done.
REFUND POLICY: If you are due a refund from Eye Care Associates of Denton, there will be a processing period to verify all funds are due back to you and that the payment you or your insurance has made has cleared the bank. If you pay a deposit and cancel your procedure please know there will be a $25.00 administration fee deducted from the amount that is to be refunded.
PATIENT STATEMENT: I have been informed of the Eye Care Associates of Denton, Dr. Nadeem Haq?s financial policy and agree to its terms. I have been notified that Medicare and other insurance companies may deny payment for my office visit for the reasons stated above. If Medicare or my other insurance company denies payment, I agree to be personally and fully responsible for payment.
I have read and understand the Financial Policy of Eye Care Associates of Denton. I have read the Refraction Service and Fee Policy and understand that the refraction is a non-covered service. I accept full financial responsibility for the cost of this service and understand it is due at the time of service. I understand that any copayment, coinsurance or deductible I may have are separate from the refraction fee.
Consent for Treatment
I understand that medical treatment may be necessary and I hereby consent to authorize the administration of all diagnostic and therapeutic treatments that may be considered advisable or necessary in the judgment of the physician. I understand that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of my examination, care and treatment.
