O pi

Dear:

Thank you for selecting Colorado Cataract & Laser, LLC for your eye care needs. We are committed to providing quality eye care and look forward to meeting you.

We have enclosed our new patient forms, with basic information needed for your medical record.

Please complete the forms and bring them with you to your first appointment.

Bring a current list of all medications and dosages. If you are not sure of the dosages or cannot read the prescription labels, please bring the actual medications with you to your first appointment.

If you currently wear glasses, bring them with you.

Bring your insurance cards. For our insurance records, we will copy them and keep them in your medical record. Should your insurance carrier require a referral, please bring one with you.

Please be prepared to pay your Specialist Co-pay at time of service. Your first visit at Colorado Cataract & Laser, LLC will consist of a complete eye exam. This initial visit usually lasts about 2 hours, but may vary in length depending on the diagnosis made by your doctor. Your eyes may be dilated during this visit. We recommend you bring a pair of sunglasses to protect your eyes from the sun. You may want someone to drive you home.

Your appointment is scheduled with:

Dr. _____________________________

On: ________________________________ at: _______________________________ a.m. /p.m.

Location:

Parker Aurora

Our Parker Location is located on 1st floor of the Sierra Bldg. by the Parker Adventist Hospital.Our Aurora office is located at the Medical Center of Aurora, North side of Hospital.

A map is attached with our address and telephone numbers.

If you would like more information, please call our office at 303-337-3937.

Colorado Cataract & Laser, LLCThe Center for Eye Care Excellence

* Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma303-337-3937

Aurora Location1411 South PotomacSuite 140Aurora, CO 80012Just southwest of Mississippi and Potomac connected to the Medical Center of Aurora

From 225, take the Mississippi exit and head WEST towards the mountains. Stay in the left lane and go left at the first light – Potomac Street. We are located on the right side connected to the hospital – Medical Center of Aurora.

Parker Location9399 Crown Crest BoulevardSuite 120Parker, CO 80138Just southeast of Parker Road and HWY 470 connected to the Parker Adventist Hospital in the Sierra Building

From Parker Road and E470 head southeast on Parker Road and turn left on Crown Crest Boulevard. Pass the round-a-bout and take the 2nd entrance into the hospital parking lot. We are in the Sierra Building in suite 120.

Colorado Cataract & Laser, LLCThe Center for Eye Care Excellence

Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma

Patient Registration Form

Patient Information:

Patient Name: ____________________________________________________________________ Date: _______________________ Last First Middle

Date of Birth: __________________________ Social Security No: ___ ___ ___-___ ___ -___ ___ ___ __ Male Female

Marital Status: Single Married Divorced Separated Other

Race: American Indian/Alaska Native Asian Black/African American

Native Hawaiian/Other Pacific Islander Caucasian

Ethnicity: Hispanic/Latino Not Hispanic/Latino

Address: ______________________________________ City: ______________________________________State: _________ ZIP______________

Home Phone: _______________________ Cell Phone: _______________________ Email Address: __________________________________

Emergency Contact __________________________________________________ Phone Number _____________________________________

Employer: _____________________________________________________ Employer Work Phone: __________________________________

Health Care Providers:

Referring Physician _____________________________________________ Phone: ________________________Primary Care Physician _____________________________________________ Phone: ________________________Specialty Care Physician(s) _________________________________________ Phone: ________________________ Preferred Pharmacy and Location: _________________________________ Phone: ________________________

Insurance and/or Responsible Party:

Medical Insurance Primary Carrier: __________________________________________________________________

Primary Holder Name: _____________________________ Primary Holder Date of Birth: _______________

Primary Holder SSN# _______________ ID# __________________________ Group# _______________

Medical Insurance Secondary Carrier: __________________________________________________________________

Primary Holder Name: _____________________________ Primary Holder Date of Birth: _______________

Primary Holder SSN# ______________________________ ID# __________________________ Group# _______________

(Over, please)

Vision Insurance Carrier: __________________________________________________________________

Primary Holder Name: _____________________________ Primary Holder Date of Birth: _______________________

Primary Holder SSN# ____________________________ ID# __________________________ Group# _____________________ Financially Responsible Party for Today’s Visit: _________________________________________________________

Relationship to patient: Self Spouse Dependent Child Other _________________________________Worker’s Compensation:

Is your visit today injury related? Yes No If yes, Date of Injury _____________________________________

Worker’s Compensation Insurance Carrier: ___________________________________________________________________

Claim # ___________________________ Employer: ___________________________________________________________________

Claim Mailing Address: __________________________________________________________________________________________

Reason for Today’s Visit:

Chief complaint (Please check the reason(s) for your visit)

blurry spot in vision dizziness glare pain in eye(s) blurry vision double vision glasses re-check red eye(s) bump on eyelid(s) droopy lid(s) glaucoma evaluation swelling burning sensation dry eye(s) headaches watery eye(s) crossed eye(s) eye lashes turning in itchy eye lids wishing to be free of glass or contacts diabetic eye exam flashes itchy eyes routine eye exam discharge floaters injury foreign body sensation distorted vision loss of vision cataracts other: ________________

severity none minimal mild significant moderate severe location right Eye left Eye both eyes other ___________________________ timing none intermediately constantly occasionally once

This has been going on for ____ Hours _____ Days _____ Weeks _____ Months

Colorado Cataract & Laser, LLCThe Center for Eye Care Excellence

* Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma

Medical History Form

Patient Name: (Last, First, M.I.) _____________________________________________________________ Date: __________________________

Date of Birth: ________________________ Occupation: ________________________

Date of Last Eye Exam: __________________________ Date of Last Physical Exam: _________________________

ALLERGIES Do you have allergies to any medications? Yes NoIf yes, please list medications: _____________________________________________________________________________

CURRENT MEDICATIONS (include vitamins and supplements)

MEDICAL HISTORY (do you have or have you been treated for):

□ Acne □ Abdominal Pain □ Allergies□ Anemia□ Anxiety□ Arthritis□ Asthma□ Autoimmune Disease□ Back/Neck Problems□ Bleeding Disorders□ Blood Disorders □ Blood in Urine□ Bronchitis□ Cancer___________________□ Chest Pain□ Congestive Heart Failure□ COPD□ Cough□ Diabetes□ Depression□ Diarrhea□ Dryness□ Emphysema□ Fatigue

□ Fever□ GI Problems□ GYN Problems□ Hay fever□ Headaches□ Hearing Disorder□ Heart Attack□ Heartburn□ Heart Disease□ Heart Murmur□ Hepatitis Type_____________□ Herpes□ High Blood Pressure□ High Cholesterol□ HIV □ Irregular Heartbeat□ Joint Pain□ Kidney Disease□ Leukemia□ Liver Disease□ Muscle Aches□ Numbness□ Pacemaker□ Pain

□ Palpitations□ Paralysis□ Prostate□ Psoriasis□ Prostate Problems□ Psych Disorder□ Rash□ Rosacea□ Seasonal Allergies□ Seizures□ Shortness of Breath□ Sinus Problems□ Skin Conditions□ Sleep Apnea□ Sore Throat□ Stroke□ Swollen Joints□ Thyroid Problems□ Ulcers□ Urinary Disorder□ Weakness□ Weight Loss/Gain□ Wheezing

□□ Diabetes: Insulin Dependent _____Yes _____No Cause____________________________ Year Diagnosed_____________□ Other illnesses/injuries: □ Additional Info: ___________ □ SURGICAL HISTORY (please list all prior surgeries and year they occurred)□ □ □ □□ SOCIAL HISTORY□ Do you drink alcohol? Yes No Drinks per week __________□ Do you smoke? Yes No Packs per day ____________ # of Years ___________

□ Previous smoker? Yes No Packs per day ____________ # of Years ___________ Quit ______□ Recreational Drug Use? Yes No Type ___________________ # of Years ___________ Quit ______□

□ (Over Please)

□□□□□ FAMILY HISTORY (please indicate relationship to patient – mother, father, grandparent, etc.)□ Y N High Blood Pressure _________________________ Y N Glaucoma __________________________________□ Y N Diabetes ___________________________________ Y N Macular Degeneration ________________________□ Y N Cancer ____________________________________ Y N Cataracts ___________________________________□ Y N Heart Disease _______________________________ Y N Retinal Detachment __________________________□ Other __________________________________________ Y N Lazy Eye/Crossed Eyes ________________________□□ REVIEW OF SYSTEMS (do you currently have any of the following problems?)□ YES NO EXPLAIN

□ Chronic fever, Unexpected weight loss/gain or Fatigue □ □ _________________________□ Ears/Nose/Throat (hearing loss, sinus problems, sore throat) □ □ _________________________□ Cardiovascular (chest pain, irregular heart beat) □ □ _________________________□ Respiratory (asthma, shortness of breath, wheezing, cough) □ □ _________________________□ Gastrointestinal (heartburn, abdominal pain, diarrhea) □ □ _________________________□ Genitourinary (urinary problems, pain, blood in urine) □ □ _________________________□ Dermatological (acne, rashes, dryness, rosacea, psoriasis) □ □ _________________________□ Musculoskeletal (muscle aches, joint pain, swollen joints) □ □ _________________________□ Neurological (numbness, weakness, headaches, paralysis) □ □ _________________________□ Hematologic/Lymphatic (blood disorders, leukemia) □ □ _________________________□ Allergic/Immunologic (hay fever, allergies) □ □ _________________________□ Endocrine (thyroid problems, diabetes) □ □ _________________________□ Psychiatric (depression, anxiety) □ □ _________________________□□ EYE HISTORY (do you have or have your been treated for) check all that apply□ □ Cataracts □ Iritis/Uveitis □ Retinal Tear□ □ Glaucoma □ Dry Eye □ Retinal Detachment□ □ Amblyopia (lazy eye) □ Macular Degeneration □ Double Vision□ □ Strabismus (crossed eye) □ Floaters □ Macular Hole□ □ Blepharitis (eyelid inflammation) □ Eye Allergies □ Eye Injury______________________________□ (explain)

□ EYE MEDICATIONS EYE SURGERIES/LASERS (indicate which eye and year of procedure)

□

□ □ _________________________________________________ _____________________________________________________________________□□ CURRENT SYMPTOMS (are you currently having any of the following eye problems? If yes, explain)□ Do you wear glasses? Yes No□ Do you wear contacts? Yes No Type _____________________________________________□ Do you have blurred vision? Yes No ______________________________________________________□ Do you have difficulty driving due to vision? Yes No ______________________________________________________□ Do you have problems with night vision? Yes No ______________________________________________________□ Loss of central or peripheral vision? Yes No ______________________________________________________□ Glare/Light Sensitivity? Yes No ______________________________________________________□ Dryness? Yes No ________________________________________________________________□ Tearing? Yes No ________________________________________________________________□ Itching/Allergies? Yes No ________________________________________________________________□ Mucous Discharge? Yes No ________________________________________________________________□ Redness? Yes No ________________________________________________________________□ Foreign body sensation? Yes No ________________________________________________________________□ Infection Eye or Lid? Yes No ________________________________________________________________□ Eye Pain/Soreness? Yes No ________________________________________________________________

□ Double Vision? Yes No ________________________________________________________________□ Floaters/Flashes of Light? Yes No ________________________________________________________________□ Crossed Eye? Yes No ________________________________________________________________□ Drooping Eyelid? Yes No ________________________________________________________________□□ Are you interested in learning if you are a candidate for LASIK? Yes No

□□

□ Colorado Cataract & Laser, LLC□ The Center for Eye Care Excellence

□ Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma

□

□□

□□

□

□ Colorado Cataract and Laser, L.L.C.

□ Agreement of Responsibility □ I understand that professional services, diagnostic tests and other medical services rendered to the patient are the financial

responsibility of the patient or the patient’s guarantor (the responsible party in the case of minors). I understand that I am financially responsible for all charges not covered by my insurance company.

□

□ Eyeglass Prescription (Refraction ) : I understand that refraction is a service that is not covered by Medicare or most health insurance carriers. If your doctor provides a refraction with an eyeglass and/or contact prescription, you will be responsible for this charge, which is payable at the time of service.

□

□ Consent to Treat: □ I voluntarily consent to such care and treatment as prescribed by the physician as is necessary in his or her judgment.□

□ Release of Information Assignment of Benefits: □ I authorize use of this form on all my insurance submissions and authorize release of information needed to process a claim

to any of my insurance companies. I permit a copy of this to be used in place of the original. I authorize the provider to act as my agent in helping me obtain payment from my insurance companies. I understand the provider does not accept responsibility for collecting my insurance claims or for negotiating a settlement in disputed claims. I assign any rights and claims for reimbursement of expenses allowable under my insurance plan and authorize payment directly to the provider for services rendered. I understand I will receive a monthly statement for any balance due by me.

□ I hereby authorize Colorado Cataract & Laser, L.L.C., its agents, employees and affiliates to have access to my complete medical records for the purpose of performing its billing and management functions as they deem necessary.

□

□ Medicare Authorization (if applicable): □ I request payment of authorized Medicare benefits be made on my behalf to Colorado Cataract & Laser, LLC for any services

furnished to me by that physician or supplier. I authorize the holder of medical information, about me, to release to Medicare and its agents any information needed to determine these benefits or the benefits payable to related services.

□ I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If “other health insurance” is indicated in item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes the release of the information to the insurer to the agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, co-insurance and any uncovered services. Co-insurance and the deductible are based upon the charge determination of the Medicare carrier.

□ Medigap Authorization (if applicable): □ The following is to be filled out if you have a Medigap insurance policy for which you wish to assign benefits. A Medigap or

Medicare Supplemental policy is a health insurance policy or other health plan, offered by a private company, to those entitled to Medicare benefits. It is designed to pay certain costs that Medicare does not pay. By law, his excludes a policy or plan offered by an employer to employees or former employees, as well as a policy or plan or offered by a labor organization to member or former members.

□

□ Name of Insurance □ This agreement is in effect until revoked in writing by the patient,□

□ Print Patient Name:□

□ ________________________ _______________________ _________________________□ First Middle Last□

□ Patient Signature:□

□ _________________________________________________ Date______________________□□

□

□

□ Colorado Cataract and Laser, L.L.C. Release of Information

□ Patient Name ______________________________________________ Date of Birth ____/____/_____

□ I choose not to share my information with anyone.

□ OR

□ I authorize Colorado Cataract and Laser to share information from my records with the following:

□ Share

□ ALL

□ Information

□□ Appointment□ □

□□ Treatment□

□□ Billing□

□□ Health History*□

□□ Name

_____________________________

□□ Relationship

________________________

□□□□

□□□□

□□□□

□□□□

□□ Name

_____________________________

□□ Relationship

________________________

□□□

□

□□□□

□□□□

□□□□

□□ Name

_____________________________

□□ Relationship_

_______________________

□□□□

□□□□

□□□□

□□□□

□

□ *The following information will not be released unless noted here:

□ □

□ Substance

□ HIV□

□ Pregnancy

□ Mental□ Health

□ Sexually□ Transmitt

ALL □

□ Abuse□

□ □ Abortion□

□ ed□

Diseases□□ Name

_____________________________

□□

□□□□

□□□□

□□□□

□□□□

□□□□

□□ Name

_____________________________

□□

□□□□

□□□□

□□□□

□□□□

□□□□

□□ Name

_____________________________

□□

□□□□

□□□□

□□□□

□□□□

□□□□

□

□ I understand that once this information is released, it is subject to redisclosure by the receiving party.

□ Signature _______________________________________________ Date ____________________________

□ Patient must sign, except where there is a Power Of Attorney on file, legal guardianship or the patient is a minor.

□ This lifetime authorization may be revoked at anytime.

□

□ Colorado Cataract & Laser, LLC□ The Center for Eye Care Excellence

□ Routine and Medical Eye Exams * LASIK/Laser Refractive Surgery * Cataract/Implant Surgery * Glaucoma

□

□

□

□ Acknowledgement of Receipt of

□ Notice of Privacy Practices

□ I, ___________________________________, have received the

□ Notice of Privacy Practices from Colorado Cataract and Laser, L.L.C.

□

□ X___________________________________ Date:___________________

□

□

□

□

□

□ Colorado Cataract and Laser, L.L.C. Staff Only:

□ In Lieu of patient signature, I, _______________________________,

□ A staff member of Colorado Cataract and Laser, L.L.C., state that the patient,

□ ___________________________

□ Has been given our

□ Notice of Privacy Practices.

□

□

□

□□

□□

□

□ Summary of Our Notice of Privacy Practices□ Colorado Cataract and Laser, L.L.C.

□ Effective Date: October 3, 2014

□ THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. Please review the full Notice of Privacy Practice (NPP) which is available to you. If you have any questions about this notice, please contact the Administrator at (303) 337-3937.

□ WHO WILL FOLLOW THIS NOTICE:

Colorado Cataract and Laser, L.L.C.

□ This notice describes our privacy practices. All these entities, sites and location follow the terms of this notice. In addition, these entities, sites and locations may share health information with each other for treatment, payment, or health care operations purposes described in this notice.

□ OUR PLEDGE REGARDING HEALTH INFORMATION:

□ We understand that health information about you and your healthcare is personal. We are committed to protecting health information about you. We created a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

□ We are required by law to:

Make sure that health information that identifies you is kept private;

Give you this notice of our legal duties and privacy practices with respect to health information about you; and

Follow the terms of the notice that is currently in effect.

□ HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:

□ The following categories describe different ways that we use and disclose health information. By coming for care, you give us the right to use your information for treatment, to get reimbursed for your care, and to operate our organization.

□ There are also various other ways in which we may use or disclose your information:

Appointment reminders

Health-related services and treatment alternatives

To provide information about Organ and Tissue Donation

To allow oversight of the quality of the healthcare we provide

To allow Workers’ Compensation Claims

As required by Subpoena in Lawsuits and Disputes

Various uses as required by law or to avert a serious threat to Health or Safety

□□

□

□

□ The full details for all these uses are contained in the full NPP.

□ YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU:

□ You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy

Right to Amend

Right to an Accounting of Disclosures

Right to Request Restrictions

Right to Request Confidential Communications

Right to a Paper Copy of this Notice

□ Information on how to exercise these rights can be seen in the NPP or can be obtained from the Administrator at

□ (303) 337-3937

□ CHANGES TO THIS NOTICE

□ We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our facility. The notice will contain on the first page, in the top right-hand corner, the effective date. In addition, each time you register for treatment or heath care services, we will offer you a copy of the current notice in effect.

□ COMPLAINTS

□ If you believe your privacy rights have been violated you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact the administrator. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

□ OTHER USES OF HEALTH INFORMTION

□ Other uses and disclosures of health information not covered by this notice of the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provide to you.

□