COLUMBIADOCTORS OPHTHALMOLOGY 635 W. 165 th Street, New York, NY 10032 880 3 rd Avenue 2 nd Floor, New York, NY 10022 15 W. 65 th Street, New York, NY 10023 119 Prospect Avenue, Ridgewood, NJ 07450 PATIENT REGISTRATION INFORMATION Date: ____________ MR#:______________ Date of Birth: _____________ Age: ______________ Last Name: __________________ First Name: ____________________ Middle Initial: ____ Gender: Male Female Address: ___________________________________________Apt#:_____________ City: _________________________ State: ___________ Zip Code: __________ Home Phone: ____________________ Cell Phone: ____________________ Email: ___________________________________ Marital Status (circle one): Single/Married/Div./Sep./Widowed Spouse’s Name (if applicable): _____________________ Mother’s First Name: __________________________ Father’s First Name: _____________________________________ Employer: _____________________________________________ Occupation: _________________________________ Business Address: ________________________________________________ Business Phone: ___________________ Primary Care Physician: ______________________________________ Phone: _________________________________ Address: __________________________________________________________________________________________ Pharmacy Address: ______________________________________________ Phone: ____________________________ Referred by: ___________________________________ In case of emergency, who should we contact? __________________________________ Phone: ___________________ Workman’s Compensation: _______________________ No Fault: ___________________________ PRIMARY INSURANCE: Person responsible for account: _______________________________ Phone: _________________________________ Relationship to Patient: _______________________ Date of Birth: _______________ Address (if different from patient): _____________________________________________________________________ Ins. Company: ___________________________Ins. Company Address: ______________________________________ Subscriber ID#: _____________________________ Group #: _________________________Co-pay: $______________ ADDITIONAL INSURANCE: Person responsible for account: _______________________________ Phone: _________________________________ Relationship to Patient: _______________________ Date of Birth: _______________ Address (if different from patient): ______________________________________________________________________ Ins. Company: ___________________________Ins. Company Address: _______________________________________ Subscriber ID#: _____________________________ Group #: _________________________Co-pay: $______________ Signature of Responsible Party: ____________________________________ Date:_____________________
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COLUMBIADOCTORS OPHTHALMOLOGY
635 W. 165th Street, New York, NY 10032 880 3rd Avenue 2nd Floor, New York, NY 10022 15 W. 65th Street, New York, NY 10023 119 Prospect Avenue, Ridgewood, NJ 07450
PATIENT REGISTRATION INFORMATION
Date: ____________ MR#:______________ Date of Birth: _____________ Age: ______________
Last Name: __________________ First Name: ____________________ Middle Initial: ____ Gender: Male Female
In case of emergency, who should we contact? __________________________________ Phone: ___________________
Workman’s Compensation: _______________________ No Fault: ___________________________
PRIMARY INSURANCE:
Person responsible for account: _______________________________ Phone: _________________________________
Relationship to Patient: _______________________ Date of Birth: _______________
Address (if different from patient): _____________________________________________________________________
Ins. Company: ___________________________Ins. Company Address: ______________________________________
Subscriber ID#: _____________________________ Group #: _________________________Co-pay: $______________
ADDITIONAL INSURANCE:
Person responsible for account: _______________________________ Phone: _________________________________
Relationship to Patient: _______________________ Date of Birth: _______________
Address (if different from patient): ______________________________________________________________________
Ins. Company: ___________________________Ins. Company Address: _______________________________________
Subscriber ID#: _____________________________ Group #: _________________________Co-pay: $______________
Signature of Responsible Party: ____________________________________ Date:_____________________
Columbia Ophthalmology Consultants Patient Medical History Questionnaire
PATIENTN~ .DOB: _
ALLERGIES: _
SENSITIVE TO: SOAPS? (1YES [1NO TAPES? [] YES (J NO OTHER _WOMEN, ARE YOU PREGNANT? [] YES [ ] NODO YOU EVER TAKE ASPIRIN, PLAVIX, COUMADIN, LOVENOX []YES [] NOEYE OR EYELID RELATED PROBLEMS: [] NO
[ ] Never [] Past[ ] Never [ ] Rare or Social[ ] Recovering alcoholism
Drug use: [ ] Never [ ] Past
[] Current packs/ day[] Small Amount Daily[] Chronic Current Use[] Current
CURRENT MEDICATIONS (including Supplements and Herbals): _
Primary Care Physician: Telephone: _Address:Preferred Pharmacy: Telephone: _Remewedby: ~D
COLUMBIADOCTORS OPHTHALMOLOGY
Date: __________________________________________________________________________ Name: _________________________________________________________________________ Physician you are seeing today: _____________________________________________________ In addition to our medical ophthalmology services, our physicians also specialize in laser refractive surgery (LASIK, Wavefront, PRK) and numerous aesthetic and rejuvenation procedures around the eyes. To ensure we are meeting our patitns’ needs, we ask that you complete the following questionnaire. Please check all that apply. These are the areas of interest or concern to me:
Laser refractive surgery (LASIK, Wavefront, PRK) Droopy upper or lower eyelids Excess skin on the eyelids Droopy or angry appearing eyebrows Bags under the eyes Bumps or skin tags on the eyelids or face Wrinkles and fine lines Skin discoloration or hyperpigmentation Dark circles or puffiness around the eyes Desire for longer, fuller or darker eyelashes Botox Dermal fillers (Juvederm, Restylane, Radiesse) None of the above concerns me
Do we have your permission to send information via email/mail or call you regarding the above procedures and updates about our practice?
Yes No, please do not contact me Email address: ______________________________________________________ Telephone number: __________________________________________________ How did you hear about us (please specify): My physician: ________________________________ A friend or family member: ______________________ Internet: _____________________________________ Other: ______________________________________
Patient Name: ______________________________________ D.O.B.: ___________________________ I, ___________________________________________________________________, give my consent to ColumbiaDoctors Ophthalmology, or any person designated by Dr. Bryan Winn to photograph me during the course of my treatment(s) in order to demonstrate my condition or disorder, subsequent therapy, including surgical procedures when I may be sedated or anesthetized, and the results of such therapy. I understand that such photographs will be treated as confidential except as authorized by me in writing. I agree that such photographs become the sole property of ColumbiaDcotros Ophthalmology/Columbia University and that they may dispose of them at any time. (Please cross out any area in which you do not wish to participate). I further give my consent to ColumbiaDoctors Ophthalmology, or any person designated by Dr. Bryan Winn to use photographs of me for the following use:
________ Scientific papers, publications in medical journals, medical and paramedical personnel trainings, and membership requirements for medical societies and certification boards.
________
Promotional purposes (i.e. practice brochures, website, newsletters and external advertisements.) I understand that at no time will my personal information and/or name be used.
________
I waive all rights of publicity and release ColumbiaDoctors Ophthalmology and its employed or contract photographers from liability with respect to reputable uses of my said photographic image and verbal testimonials for promotional purposes.
________
I understand that this authorization is valid for all pictures taken during the course of my treatment(s). If at any time I wish to revoke this authorization I agree to notify ColumbiaDoctors Ophthalmology in writing of my wishes.
Name of Beneficiary: ______________________________________________
Health Insurance Claim #: __________________________________________
I request that payment of authorized health insurance benefits, including Medicare and Medigap, be made
either to me or on my behalf to Dr.________________ for services furnished to me by this provider. I authorize
any holder of medical information about me to release to the Health Care Financing Administration and its
agents, any information needed to determine these benefits payable for related services.
Signature of Responsible Party: __________________________________ Date: _____________
Commercial Insurance
I hereby authorize direct payment of surgical/medical benefits to Dr._________________ for services rendered
by him/her in person or under his/her supervision. I understand that I am financially responsible for any balance
not covered by my insurance, including co-pays, deductibles, refractions, and differences between surgeon’s
charges and allowable. I hereby authorize Dr.______________________ to release any medical or incidental
information that may be necessary for either medical care or in processing applications for financial benefits.
Signature of Responsible Party: __________________________________ Date: _____________
Advance notice regarding Insurance Reimbursement and Beneficiary Agreement
I have been informed that refraction (the measurement of one’s eyeglass prescription and the determination of
the best visual sharpness) is usually not considered by insurance companies, health maintenance
organizations, and Medicare to be medically reasonable of necessary. Knowing this, I have instructed the
doctor to proceed with the services. If insurance decides to reduce or even deny the fee or services, I agree to
pay the doctor’s fee in full.
Signature of Responsible Party: _________________________________ Date: ______________
Revised October 2007
Health Insurance Portability and Accountability Act (HIPAA) HIPAA Compliance/Columbia University Medical Center 630 West 168th Street, Box 159 New York, NY 10032/ T(212) 342-0059 F(212)342-5173 http://www.cumc.columbia.edu/hipaa/
NOTICE OF PRIVACY PRACTICES
ACKNOWLEDGEMENT OF RECEIPT
DATE:___________________
I acknowledge that I was provided with a copy of the Columbia University Medical Center Notice of Privacy Practices.