- board certified - (601) 366-1085 kirk r. jeffreys, m.d...

• LASIK• CATARACT SURGERY• PREMIUM IMPLANTS• EYE EXAMS• EYEWEAR

(601) 366-1085

1501 Lakeland Dr. Suite 100Jackson, MS 39216www.eyecare4ms.comA full-service ophthalmology practice.

Kirk R. Jeffreys, M.D.- Board Certified -

P R O F E S S I O N A L S

P R O F E S S I O N A L SA full-service ophthalmology practice.

1501 LakeLand drive

Suite 100

JackSon, MS 39216

601.366.1085

eyecare4MS.coM

Patient registration form

EYECARE PROFESSIONALS, P.A. PATIENT REGISTRATION FORM

PATIENT NAME _______________________________________________________________ DATE _____________________________

SOCIAL ADDRESS _______________________________________________________________ SECURITY # _______________________ _______________________________________________________________ DATE OF BIRTH _______________ ____ EMAIL ADDRESS _______________________________________________________ AGE _________ SEX : ( ) M ( ) F EMPLOYER _______________________________________________________________ HOME PHONE (____)________________ STUDENT ( ) FT ( ) PT COLLEGE/SCHOOL ______________________________ WORK PHONE (____)________________ MARITAL STATUS ( ) S ( ) M ( ) D ( ) W CELL PHONE (____)________________ SPOUSE’S NAME ____________________________DATE OF BIRTH________________ WHO REFERRED YOU TO OUR CLINIC?

__________________________________

WHAT IS YOUR REASON FOR TODAY’S VISIT?______________________________________________________________________

EMERGENCY CONTACT___________________________________________________ PHONE ( ) ______ RESPONSIBLE PARTY SOCIAL NAME _______________________________________________________________ SECURITY # _______________________ ADDRESS _______________________________________________________________ HOME PHONE (____)________________ _______________________________________________________________ WORK PHONE (____)________________ RELATIONSHIP TO PATIENT _______________________________________________________________ CELL PHONE (____)________________ EMPLOYER _______________________________________________________________

INSURANCE COVERAGE ___ VISION PLAN ___MEDICARE ___ NO INSURANCE ___ CHIPS ___ MEDICAID ___ OTHER: _____________________

PRIMARY __________________________________________ SECONDARY ___________________________________________

POLICY NUMBER____________________________________

POLICY HOLDER’S NAME (IF DIFFERENT THAN PATIENT)_____________________________________________________________

ADDRESS______________________________________________________________________________________________________

SOCIAL SECURITY #______________________________________ DATE OF BIRTH________________________________________

PLEASE PRESENT INSURANCE CARDS & DRIVERS LICENSE TO RECEPTIONIST

CONSENT TO TREAT / AUTHORIZATION TO RELEASE INFORMATION

I authorize the Physicians of Eyecare Professionals, P.A. (Practice) to provide treatment and use my health information for treatment, payment, and healthcare operations, which includes submitting information to my insurance company for the purpose of processing claims. I further authorize non- Practice labs, radiology centers, Pathologists, and Radiologists who may interpret and/ or report on diagnostic tests ordered by Practice to provide such treatment and use my health information for billing and payment. I am responsible for payment of services rendered to me by Practice. If I am under 18, parent / guardian requesting treatment assumes responsibility. Full payment is due at the time of service unless I am covered by an accepted insurance or third party coverage plan. I understand that if my account should ever require action by a collection agency in order to collect the balance owed, fees charged by these agents may be added to the balance due on my account.

I hereby acknowledge and agree to accept the policies stated above. _________________________________________ _________________________________________ ____________________ Signature of Patient Parent/ Guardian(if under 18) Date

FIRST MIDDLE LAST

LifestyLe® Vision Questionnaire


(601) 366-1085





1501 LakeLand drive

Suite 100

JackSon, MS 39216

601.366.1085

eyecare4MS.coM

read newspapers/Books

read Medicine Bottles

needlepoint/Sew

Participate in Water Sports

drive – daytime

drive – nighttime

Shop

use iPhone/Blackberry

Play tennis

Hunt or Fish

Paint/draw

Watch Spectator Sports

How important is it for you to read or use the computer without glasses?

do you wear glasses now?

no yes

if Yes,... all the time Sometimes only for far distances

only for reading only for the computer

name date

very important important not important

close to your face chest level in your lap

We recognize that your eyes are very important to you. We would like to know how you use your eyes on a daily basis. along with your eye exam, this information will assist us in recommending the best options for your eyes and your personal Lifestyle vision.

read? hours use the computer? hours

How many hours per day do you:

Where do you hold your book when reading?

How do you feel about wearing glasses?

do you drive at night? if Yes, how often?

if it were possible to go without glasses most of the time, would you like that?

yes

yes

no

no occasionally nightly as a profession (truck, cab, etc.)

What occupational, recreational, or other activities do you currently engage in that are not listed above?

Please check the box on the following scale that best describes your personality type:

easy Going Perfectionist

read newspapers/Books

read Medicine Bottles

needlepoint/Sew

Participate in Water Sports

drive – daytime

drive – nighttime

Shop

use iPhone/Blackberry

Play tennis

Hunt or Fish

Paint/draw

Watch Spectator Sports

Play a Musical instrument

dine in restaurants

Bicycle

Play cards/dominos

use the computer

Golf

use cell Phone

Watch Movies in theatre

Photography

cook

Paperwork/Writing

Play a Musical instrument

dine in restaurants

Bicycle

Play cards/dominos

use the computer

Golf

use cell Phone

Watch Movies in theatre

Photography

cook

Paperwork/Writing

check the following activities that you currently do on a regular basis:

check the following activities that you would like to do without glasses, if possible:


(601) 366-1085





1501 LakeLand drive

Suite 100

JackSon, MS 39216

601.366.1085

eyecare4MS.coM

authorization to discLose heaLth information

name

I authorize the use or disclosure of the above named individual’s health information as described below.

the following individual or organization is authorized to make this disclosure:

the type and amount of information to be used or disclosed is as follows (includes dates):

i understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (aidS), or human immunodeficiency virus (Hiv). it may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

this information may be disclosed to and used by the following individual or organization:

For the purpose of:

i understand that i have a right to revoke this authorization at any time. i understand if i revoke this authorization i must do so in writing and present my written revocation to Bobby Moss. i understand that the revocation will not apply to information that has already been released in response to this authorization. i understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. unless otherwise revoked, this authorization will expire on the following date, event, or condition:

if i fail to specify an expiration date, event, or condition, this authorization will expire in six months.

i understand that authorizing the disclosure of this health information is voluntary. i can refuse to sign this authorization. i need not sign this form in order to assure treatment. i understand that i may inspect or copy the information to be used or disclosed, as provided in cFr 164.524. i understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. if i have questions about disclosure of my health information; i can contact Bobby Moss at 601-366-1085 or 866-366-1085.

date of Birth

SiGnature oF Patient or LeGaL Guardian

iF SiGned By LeGaL rePreSentative, reLationSHiP to Patient

X

X

date

SiGnature oF WitneSS

With my consent, eyecare Professionals, P.a., may use and disclose protected health information

(PHi) about me to carry out treatment, payment and healthcare operations (tPo). Please refer to

eyecare Professionals, P.a. notice of Privacy Practices for a more complete description of such

uses and disclosures.

i have the right to review the notice of Privacy Practices prior to signing this consent. eyecare

Professionals, P.a., reserves the right to revise its notice of Privacy Practices at any time. a

revised notice of Privacy Practices may be obtained by forwarding a written request to eyecare

Professionals, P.a.’s Privacy officer at 1501 Lakeland drive, Suite 100, Jackson, Mississippi 39216.

With my consent, eyecare Professionals, P.a., may call my home or other designated location and

leave a message on voice mail or in person in reference to any items that assist the practice in carry

out tPo, such as appointment reminders, insurance items, optical goods ordered, and any call

pertaining to my clinical care, including laboratory results among others.

With my consent, eyecare Professionals, P.a., may mail to my home or other designated location

any items that assist the practice in carrying out tPo, such as appointment reminder cards and

patient statements as long as they are marked personal and confidential.

With my consent, eyecare Professionals, P.a., may e-mail to my home or other designated location

any items that assist the practice in carrying out tPo, such as appointment reminder cards and

patient statements. i have the right to request that eyecare Professionals, P.a., restrict how it uses

or discloses my PHi to carry out tPo.

However, the practice is not required to agree to my requested restrictions, but if it does, it is

bound by this agreement.

By signing this form, i am consenting to eyecare Professionals, P.a.’s use and disclosure of my PHi

to carry out tPo. i may revoke my consent in writing except to the extent that the practice has

already made disclosures in reliance upon my prior consent. if i do not sign this consent, eyecare

Professionals, P.a., may decline to provide treatment to me.


(601) 366-1085





1501 LakeLand drive

Suite 100

JackSon, MS 39216

601.366.1085

eyecare4MS.coM

Patient consent for use and discLosure of Protected heaLth information

Signature of Patient or LegaL guardian

Patient’S name date

X


(601) 366-1085





1501 LakeLand drive

Suite 100

JackSon, MS 39216

601.366.1085

eyecare4MS.coM

Patient financiaL resPonsiBiLity discLosure statement

Patient Financial Responsibility Disclosure Statement Your signature below forms a binding agreement between Eyecare Professionals, P.A. (the provider of vision services) and the Patient who is receiving vision services, or the Responsible Party for minor patients (those patients under 18 years old). Responsible Party is the individual who is financially responsible for payment of medical bills. All charges for services rendered are due and payable at the time of service. VISION/MEDICAL INSURANCE: We have contracts with many insurance companies, and we will bill them as a service to you. As the responsible party, you are responsible if your insurance company declines to pay for any reason. The person signing on behalf of the Patient as the Responsible Party must:

• Inform Eyecare Professionals of the current address and phone number for the patient and the responsible party.

• Present all current insurance cards prior to each office visit.

• Verify at each visit that the information is current by signing our data sheet.

• Pay any required copay at the time of the visit.

• Pay any additional amount owing within 30 days of receiving a statement from our office. (When Eyecare Professionals receives an explanation of benefits (EOB) from your insurance company, any amounts that you need to pay will be billed to you).

Returned Check Policy If a payment is made on an account by check, and the check is returned as Non-‐Sufficient Funds (NSF), Account Closed (AC), or Refer to Maker (RTM), the patient or the Patient’s Responsible Party will be responsible for the original check amount in addition to a $25.00 Service Charge. Once notice is received of the returned check, Eyecare Professionals will send out a letter to notify the Responsible Party of the returned check. If a response is not made within 15 days from the letter date by the Patient or the Responsible Party, the account may be turned over to our collection agency and a collection fee will be added to the outstanding balance – in addition to the $25.00 Check Service Charge. Non-‐Payment on Account Should collection proceedings or other legal action become necessary to collect an overdue account, the patient or the patient’s Responsible Party, understands that Eyecare Professionals has the right to disclose to an outside collection agency all relevant personal and account information necessary to collect payment for services rendered. The patient, or the patient’s Responsible Party, understands that they are responsible for all costs of collection including, but not limited to, interest due at 18% APR, all court costs and Attorney fees, and a collection fee will be added to the outstanding balance. By signing below, you agree to accept full financial responsibility as a patient who is receiving medical services, or as the responsible party for minor patients. Your signature verifies that you have read the above disclosure statement, understand your responsibilities, and agree to these terms.

Patient Name (Please Print) ______________________________________________________________________________________ Patient Signature________________________________________________________________________Date___________________ Responsible Party Name (Please Print) _____________________________________________________________________________ Responsible Party Signature ________________________________________________________________ Date _________________

- board certified - (601) 366-1085 kirk r. jeffreys, m.d...

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