New Patient Cataract Registration Form

Patient Information

First Name

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Last Name

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Middle Name

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What name do you want to be called by?

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Gender:

Male

Female

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Date of Birth:

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Martial Status

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Social Security Number

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Employer:

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Address

Street Address:

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City:

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State:

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ZIP

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Is it okay to contact you by email?

Yes

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Phone Number:

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Cell Phone Number:

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Other Number:

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Emergency Contact Information

Primary Care Physician:

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Emergency Contact (please list name, phone number and relationship):

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Who will be guaranteeing payment for today's visit? Please list name, address, telephone number and relationship if the patient is not the guarantor:

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Insurance Information

Primary Insurance:

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Policy Owner:

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Policy Number:

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Group Number:

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Secondary Insurance:

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Policy Owner:

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Policy Number:

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Group Number:

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Is this patient a minor?

Yes

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Does the patient have a legal representative?

Yes

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If yes to either, please list name, address and phone number of legal representative:

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Authorization

I authorize Haas Vision Center to release any information regarding my examination and/or treatment to any other physician, insurance company or health organization as required.

I authorize any physician, hospital or medicare care facility to provide all information regarding any health history and/or treatment to Haas Vision Center.

I authorize payment directly to Haas Vision Center for the surgical and/or medical benefits, if any, otherwise payable to me under the terms of my insurance.

I understand that I am ultimately responsible for payment for services rendered even though it may be covered by medical insurance, Workers Compensation, or a private agreement with another party.

Parent/Guardian Signature:

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Date

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Financial Policy

Haas Vision Center is a dedicated medical and surgical practice. Therefore, we do not accept any vision plan insurance. Your exam today WILL be billed under your medical insurance. Please understand that vision insurance will only cover routine vision problems such as near or far-sighted vision, eyeglasses and contacts; vision insurance will not cover medical eye conditions.

Haas Vision Center makes every effort to ensure that we participate with your health insurance. Health insurance companies are continually offering new plans with different networks. Unfortunately, the insurance companies do not always let us know if we are in network; therefore, it is impossible to know for certain that we participate with your insurance. It is the patient's responsibility to ensure we are in network before being seen by Dr.Haas. If your insurance claim comes back as out of network, you will be responsible for all charges dictated by your insurance company.

Please understnad that our financial policies are established to assure the financial resources needed to maintain this medical office for all our patients. We will work with you regarding your financial responsibility.

We must emphasize that as a health care provider our relationship with you, not your insurance company.
Your insurance is a contract between you, your employer, and the insurance company. We bill your insurance company as a courtest to you, the patient.
You are responsible for knowing what your co-payments, deductibles and/or co-insurnace is with your insurance provider. Please contact your insurance company and/or your employer's human resources department with regards to your benefit questions.

If you have health insurance with which we participate:

We will bill your insurance claim for you.
We expect any required co-payment at time of service.
We expect payment of the deductible nd coinsurance to be paid in full after we have issued you a statement to be paid within 30 days unless prior arrangements have been made.

If you are uninsured or we do not particpate with your insurance, payment for total charges are due on the day of your appointment unless prior arrangements have been made.

Late Cancellation/No Show Policy

Due to the increased demand for appointment times, it has become necessary to implement a late cancellation/no show policy for office visits. 24 HOUR NOTICE IS REQUIRED FOR ALL CANCELLATIONS. If a patient appointment has been confirmed and the patient fails to keep the appointment, it will be documented in the patient chart and a fee of $35.00 will be assessed to the patient's account.

I have read and accept the terms of this financial policy:

Patient signature (or person authorized to sign for patient)

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Today's Date:

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Information and Consent for Refraction

It may be important to your care to perform a vision test called a "refraction" to check for your BEST vision today. A refraction is when the examiner determines the prescription required for the patient's eyeglasses by evaluating the effectiveness of a series of lenses through which the patient is asked to view an eye chart. This is accomplished with a phoropter (refractor), a device that contains a range of lens powers that can be quickly changed, allowing the patient to compare various combinations when viewing the eye chart. A lens prescription is issued when the examination is complete.

Medicare, AARP and Medicare Advantage Plans DO NOT COVER refractions. If Medicare does not cover the refraction, neither will most other secondary insurances. The cost for your refraction is $50.00 which will be collected at check-out today.

Some private insurance plans will cover the cost of refractions. Therefore, we will bill your private insurance for the refraction. If the private insurance denies the refraction, we will send you a statement for the cost of the refraction ($50.00).

I understand that if I have a refraction today that the cost of the refraction will be as stated above.

Patient signature (or person authorized to sign for patient)

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Today's Date:

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Information and Consent for Dilated Eye Examination

It may be important to your care today to dilate your eyes. Dilating eye drops are used to enlarge the pupils of the eye to allow the physician to obtain a better view of the inside of your eyes.

Dilation frequently changes for vision for a length of time which varies from person to person and may make bright lights bothersome. It is not possible for us to predict to what degree your vision will be affected. Driving may be difficult immediately after the examination. If you are concerned about these problems, you may wish to make alternative transportation arrangements, although a large number of patients do drive after dilation with the assistance of temporary sunglasses, which we can provide after your dilation.

I hereby authorize the physician and/or such assistants as may be designed by him to administer dilating eye drops. The eye drops are necessary to perform a complete exam of the retina and back of the eye. This may reveal the presence of a serious systemic condition as well as eye conditions.

I agree to have the dilation examination on every visit that Dr.Haas deems it necessary to conduct a complete examination of my eyes. I understand that if I decide not to have the dilated examination, I must sign another form revoking my consent for that visit only.

Patient signature (or person authorized to sign for patient)

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Today's Date:

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HIPPA RELEASE OF INFORMATION

Release of Information

I authorize the release of information including the diagnosis, records; examination rendered to me and claims information.

This information may be released to:

Spouse:

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Child(ren):

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Other:

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Information is not released to anyone.

This Release of Information will remain in effect until terminated by me in writing.

Patient Signature:

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Today's Date:

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Receipt of Notice of Privacy Practice Written Acknowledgement Form

Our Privacy Policy(opens in a new tab)(opens in a new tab)

I have read/received/been presented with a copy of the Notice of Privacy Practices.

Signature of Patient:

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Date:

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Signature of Guardian:

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Date:

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Family Medical History

Is there a family history of:

High Blood Pressure

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If yes, who?

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Heart Disease

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If yes, who?

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Respiratory Issues

Please select an option.

If yes, who?

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Arthritis

Please select an option.

If yes, who?

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Strokes

Please select an option.

If yes, who?

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Diabetes

Please select an option.

If yes, who?

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Thyroid

Please select an option.

If yes, who?

Please complete this field.

High Cholesterol

Please select an option.

If yes, who?

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Cancer

Please select an option.

If yes, who?

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Other:

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Have you ever had any surgical procedures before?

If yes, please list procedures and dates:

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Do you receive a Flu Vaccine very year?

Please select an option.

Have you had an Pneumonia Vaccine?

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Please list ALL medications (including non prescription) you are currently taking:

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Please list all known drug allergies: (If none, please write none)

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Are you or have you ever been a smoker?

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Do you drink alcohol?

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If yes, how often?

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Vision History

Do you currently wear glasses or contacts?

Please select an option.

Have you ever had eye surgery?

Please select an option.

Have you had Lasik?

Please select an option.

Do you OR any one in your family have any history of the following:

Glaucoma

Age Related Macular Degeneration

Retinal Detachment

Cataracts

Dry Eyes

Please mark any condition you have presently or have had in the past:

High Blood Pressure

Heart Disease

Respiratory Issues

Arthritis

Strokes

Diabetes

Thyroid

High Cholesterol

Cancer

Other

Visual Function Questionnaire

Please Check All That Apply to You

Have You Been Bothered By:

Blurry Vision

Hazy Vision

Glare

Poor Night Vision

Seeing in poor or dim light

Halos

Seeing rings or stars around lights

Frequent changes in glasses

Have You Noticed Difficulty With Your Vision When You:

Work at your job

Manage your home

Get around in your home

Watch TV

Use a computer

Read newspapers

Read the telephone book

Read labels

Read price tags

Shop for groceries

Drive during daylight hours

Drive during evening/night hours

See traffic signs

Sew or do crafts

Play golf

Enjoy recreation or leisure

Recognize people

Other:

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Patient Signature

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Date

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Vision Lifestyle Survery

We want to help you maintain excellent vision. We will be evaluating you soon for cataracts. The term "cataracts" refers to a cloudy lens within the eye. When a cataract is removed, a lens implant is used to replace the cloudy natural lens. If it is determined that a lens implant is appropriate for you, your answers below will help in determining which implant best suits the demands of your lifestyle.

1) If a lens replacement is recommended for you, please rate your vision preference at the following distances:

Distance Vision: driving, golf, tennis, other sports, watching TV

Please select an option.

Mid-range Vision: computer, menus, price tags, cooking, board games

Please select an option.

Near Vision: reading books and newspapers, doing detailed handiwork

Please select an option.

2) Please check the single statement that best describes you in terms of night vision:

Night vision is extremely important to me and I require the best possible quality

I want to be able to drive comfortably at night but I would tolerate some slight imperfections

Night vision is not important to me

Please select an option.

3) If you had to wear glasses after surgery for only one activity, for which type of activity would you be most willing to wear glasses?

Distance Vision (driving/watching TV)

Mid-range Vision (computer/dashboard)

Near Vision (reading fine print)

Please select an option.

4) If you could have good distance vision during the day without glasses and good near vision for reading without glasses, but the compromise was that you might see some halos or rings around lights at night, would that be ok?

Please select an option.

5) If you could have good distance vision and mid-range vision during the day and night without glasses, but the compromise was that you might need glasses for reading the finest print at near, would you like that option?

Please select an option.

6) How many hours per day do you spend:

On the computer:

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Reading books, newspapers or small print:

Please complete this field.

Driving:

Please complete this field.

List your favorite hobbies or work activities

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On a scale of easygoing to perfectionist, how would you describe your personality?

Please select an option.

Patient Signature:

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Date

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Pre-Operative Questions for Cataract Surgery

1) Have you worn contact lenses within the past two weeks?

Please select an option.

If Yes:

Soft Contact Lens: please do not wear for 2 weeks prior to consult

Hard Contact Lens: please do not wear for 1 month prior to consult

2) Have your ever had any eye surgery before? (Lasik, Lasek, PRK, RK, cornea, strabismus etc.)

Please select an option.

3) If yes, what type of surgery?

Please complete this field.

If the surgery was LASIK was it for nearsighted or farsighted?

Please select an option.

4) Have you ever used any of the following medicines (even once)?

Flowmax or Tamsulosin

Cardura or Doxazosin

Minipress or Prazosin

Hytrin or Terazosin

Saw Palmetto

Uroxatral or Alfuzosin

Rapaflo or Silodosin

Proscar or Finasteride

Avodart or Dutasteride

Patient Signature:

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Date:

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How Did You Hear About Us?

Haas Vision Center would appreciate if you took the time to let us know how you heard about us.

Please check all that apply

Yellowbook Yellow Pages

Yellowpages.com

Dex Yellow Pages (or Dex Online)

Google

KOAA.com

Yahoo

Facebook

Bing

Twitter

Other:

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Referred by physician:

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Referred by optometrist:

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Referred by family/friend:

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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