1724 Rockingham Avenue, Ste. 204
Bowling Green, KY42104
270-799-2259
270-495-1310-fax
Patient Information
Patient’s Name:______Patient’s Birth Date:______/______/______
Address:______
Telephone Home ( )______Work ( )______Cell ( )______
Email: ______@______Sex: MF
Marital Status:SingleMarriedDivorcedWidowedSeparated
Employer:______
Patient’s Social Security #: ______-______-______Relationship to Insured: Self Spouse Child
Emergency Contact Name: ______Phone: ______
Referring/Primary Care Physician: ______Phone: ______
Primary Medical Insurance
Please provide copy of card with social security number and birth date of insured
Insured’s Name: ______Birth Date: ______/______/______
Relationship: ______Insured’s Social Security #: ______-______-______
Secondary Medical Insurance
Please provide copy of card with social security number and birth date of insured
Insured’s Name: ______Birth Date: ______/______/______
Relationship: ______Insured’s Social Security #: ______-______-______
It is the patient’s responsibility to contact Medical and Vision Insurance carriers to determine if we are a participating IN NETWORK physician with their plan. John E Downing, MD, PSC is a SPECIALIST office and therefore does not participate with all Routine Vision Plans.
John E. Downing, MD PSC Conditions of Service
CONSENT TO TREATMENT: I hereby consent to any routine procedures medical treatment or facility services rendered to the patient under the general and special instructions from the attending Ophthalmologist or Optometrist.
RELEASE OF INFORMATION: Subject to State and Federal regulations John E. Downing, MD PSC and/or doctor may disclose all or any part of the patient’s record for this service to any person or corporation which is or may be liable under a contract to the Doctor, or to a family member or employer of the patient for all or part of the provider’s charges, including but not limited to hospital or medical service companies, insurance companies, worker’s compensation carrier, welfare funds and all authorized auditors as specified in the Insurance Carrier Guidelines.
CHECK AGREEMENT: I hereby agree to pay a service charge of $50.00 or other amount allowed by law for each check or other instrument tendered by me but returned to John E. Downing, MD PSC. I further agree to pay all costs and expenses, including attorney’s fees, that are incurred in collection on such a returned check, draft, or money order.
MEDCIARE/MEDICAID PATIENT’S CERTIFICATION: I certify that the information given by me in applying for payment under Titles XVIII and XIX of the Social Security Act is correct. I authorize any holder of medical or other information about me release to the Social Security Administration or its intermediaries or carriers any information needed to process any claim on this or any related service. I request that payment of authorized benefits be made in my behalf directly to John E. Downing, MD PSC for its charges and for any charges of Physicians for whom the facility is authorized to bill in connection with its services.
CHAMPUS/CHAMPVA AUTHORIZATION: I request payment of authorized benefits to this facility on my behalf for any services furnished to me by this facility including Ophthalmologist/Optometrists’ services authorized to bill in connection with its services.
RECEIPT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES AND FINANCIAL POLICY: I hereby declare that I have read and understand the facility’s Policy of Privacy Practices and Financial Policy.
RELEASE OF INFORMATION: I hereby authorize John E. Downing, MD PSC to release to my insurance company and information concerning and procedures performed during this treatment and the final diagnosis as well as, information contained on this form.
RELEASE OF ACCOUNT INFORMATION: I understand any individual listed on the front of this page and any individual who can be reasonable assumed to will be authorized to retrieve any and all information pertaining to this account. This can include, but is not limited to, medical information relating to any person listed on the account as well as financial information and transactions. Furthermore, if there are any individuals whom I do not want authorized to access information, I will notify the facility HIPPA Compliance Officer in writing.
MEDICAL – CONSENT TO TREATMENT: John E. Downing, MD PSC is licensed to provide both Routine Eye Exams and Medical Eye Exams. Please be advised that if you are being seen today for a Routine Eye Exam that based upon any or a combination of the following concerns: family history, current medical disease and/or conditions, chief complaint, pre-test findings, or a condition found during the course of the exam, the Doctor may find it necessary to move from a Routine Exam to a Medical Exam as well as order additional tests. When a Medical Exam is required, be advised it is not a covered item under your Routine Eye Exam benefits through your Vision Insurance Plan. Medical exams are billed through your Major Medical Carrier and are subject to their specific Co-pay, Deductibles, and Co-Insurance which will be due at the time of service. In the event I do not wish the Doctor to proceed with a Medical Examination, I understand it is my responsibility to immediately inform the Doctor.
FINANCIAL ACKNOWLEDGEMENTS: I hereby authorize any person/institution rendering care to furnish all facts concerning this claim. I authorize payment for my medical and/or vision benefits to go directly to John E. Downing, MD PSC. I authorize John E. Downing, MD PSC to deposit checks received on my account made out to me for services rendered. I agree that if my employer, insurance carrier or plan sponsor denies payment to all or any portion of my claim, I will be financially responsible for all outstanding charges.
In the event any unpaid balance due for services rendered to me or my family remains unpaid and/or should be placed for collection, I/we agree to pay interest at the rate of 1.5% per month/18% per year, late fees of $5.00 per month, collection fees, and should legal action be filed, reasonable attorney fees, filing fees, and other costs the court determines proper. I have read the “Conditions of Service” section, and as the Patient, or the Patient’s authorized representative or General Agent for the purpose of signing this document, hereby accept it’s terms. Authorization obtained at the time of service does not guarantee payment and any denied services will be balance billed to the patient.
Patient/Guardian Signature: ______
Date:______
Please read the section “Conditions of Service”
1724 Rockingham Avenue, Ste. 204
Bowling Green, KY42104
270-799-2259
MEDICAL HISTORY QUESTIONNAIRE
Name: ______Occupation: ______
Name of Primary Care Physician: ______
Responsible Party Name, Address, SS# and Birthdate: ______
______
HIPPA NOTICE AND ACKNOWLEDGEMENT
Acknowledgement: I acknowledge that I have received and read the Notice of Privacy Practices. _____ Yes _____ No
Chief Complaint – Please check if you are experiencing any of the following:
Blurred Vision_____Glare/Light Sensitivity_____
Burning_____Itching_____
Distorted Vision/Halos_____Loss of Side Vision_____
Double Vision_____Loss of Vision_____
Dryness/Dry Eyes_____Mucous Discharge_____
Excess Tearing/Watering_____Redness_____
Eye Pain or Soreness_____Sandy or Gritty Feeling_____
Flashes/Floaters in Vision_____Tired Eyes_____
Foreign Body Sensation_____Headaches_____
Trouble with Night Vision_____
Ocular Conditions – Do you currently have or have you been diagnosed with the following:
Cataracts_____Infection of Eye or Lid_____
Crossed Eyes_____Lazy Eye_____
Drooping Eyelid_____Prominent Eyes_____
Eye Injury_____Retinal Disease_____
Glaucoma_____Styes or Chalazion_____
Eye Surgery_____
Allergies: ______
List any medications you take (including oral contraceptives, aspirin, over the counter medications and herbal supplements): ______
______
______
List all Major injuries, surgeries and/or hospitalizations you have had: ______
______
______
Are you pregnant or nursing_____ Yes_____ No
Do you wear glasses_____ Yes_____ No If yes, how old is your present pair of lenses? ______
Do you wear contact lenses?_____ Yes_____ No If yes, how old is your present lenses? ______
Type of contact lenses_____ Rigid_____ Soft_____ Extended_____ Other
Family History
Disease/Condition
Blindness………………………_____Cataract…………………………...... _____
Crossed Eyes…………………._____Glaucoma………………………………_____
Macular Degeneration…………_____Retinal Detachment/Disease………….._____
Arthritis………………………._____Cancer…………………………………_____
Diabetes………………………_____Heart Disease…………………………._____
High Blood Pressure…………._____Kidney Disease……………………….._____
Lupus…………………………._____Thyroid Disease………………………._____
Other…………………………._____
Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you would prefer.
_____ I would prefer to discuss my Social History information directly with my doctor.
Do you drive_____ Yes _____ NoIf yes, do you have visual difficulty when driving _____ Yes_____ No
If yes, please describe______
Do you use tobacco_____ Yes_____ No If yes, type and how long ______
Do you drink alcohol_____ Yes_____ No If yes, how often ______
Do you use recreational drugs_____ Yes_____ No If yes, please describe ______
Have you ever been exposed to or infected with HIV?_____ Yes_____ No
Health History
Do you currently, or have you ever had any problems in the following areas:
Allergy_____Genitourinary
CardiovascularBladder_____
Heart Trouble_____Kidney_____
High Blood Pressure_____Hematologic/Lymphatic
ConstitutionalAnemia_____
Fever_____Bleeding Problems_____
Weight Loss_____Immunologic_____
Weight Gain_____Integumentary (Skin)_____
Cranial/FacialMusculoskeletal
Chronic Cough_____ Arthritis_____
Dry Mouth_____Joint Pain_____
Ear Infection_____Muscle Pain_____
Sinus Congestion_____Neurological
EndocrineHeadaches_____
Diabetes_____Migraines_____
Thyroid/Other Glands_____Seizures_____
GastrointestinalPsychiatric_____
Constipation_____Respiratory
Diarrhea_____Asthma_____
Hepatitis_____Bronchitis_____
Emphysema_____
Our doctors routinely perform Manifest Refractions. The eye doctor can determine if you have nearsightedness, farsightedness, astigmatism (asymmetrical cornea), or presbyopia (inability to focus on objects that are close to you). The extent of vision difficulty can be determined. The information obtained from a refraction test helps provide the correct prescription for eyeglasses or contact lenses for each person. It also will determine if you need bifocals. There is an additional fee for this service and it may not be covered by some insurance plans.
Please check one of the following:
___ OK to perform tests today ___ I will reschedule these tests___ I will follow the doctor’s recommendation
Professional fees are due upon completion of services and are not refundable.
Thank you for the privilege of allowing John E. Downing, MD PSC to take care of your eye health and vision needs.
Patient/Guardian Signature:______Date: ______