New Patient Packet

Patient Information

Name

Date of Birth

SSN

Addess

City

Zip

Phone Number

Home

Sex

Male Female

Preferred Language

English Other

Please specify if other.

Occupation

Place of employment

Race

Decline Caucasian(white) Black (African American) Asian American Indian Other

Please specify if other.

Marital Status

Married Single Divorced Widowed Life Partner

Spouse or partners name

Date of Birth

SSN

Financially Responsible Party

Patient

Spouse

Parent/Guardian

Male

Female

Name

Date of Birth

SSN

Spouse or partners name

Date of Birth

SSN

Street Address

City

Zip

Phone Number

Home

Work/other

Payment Options

Insurance

Self Pay

Insurance

Insurance #1 (Primary Insurance- This will be filed first)

Insurance company

Contract Number

Group number

Subscribers Last Name

First Name

Middle Name

Social security number

Date of Birth

Sex

Male Female

Relationship to patient

Insurance #2 (Secondary Insurance-This will be filed after primary insurance pays)

Insurance company

Contract Number

Group number

Subscribers Last Name

First Name

Middle Name

Social security number

Date of Birth

Sex

Male Female

Relationship to patient

Insurance #3 (Tertiary insurance- This will be filed after primary and secondary insurance pays)

Insurance company

Contract Number

Group number

Subscribers Last Name

First Name

Middle Name

Social security number

Date of Birth

Sex

Male Female

Relationship to patient

Emergency Contact

Name

Relationship

Phone Number

Initial in the boxes.

Initials

After 2 no call-no show appointments, it will be documented in the patient’s chart and a fee of $50 will be assessed to the patient’s account and may ultimately result in dismissal from our practice.

Initials

Best possible vision measurement or RX. This is a medically non-covered service. The fee is $40.00 and is collected at time of service. We only collect if service is performed.

Initials

I have reviewed the Notice of Privacy Practices as provided at registration and understand that I may request a copy of the policy at any time.

Initials

I hereby authorize Dr. Kassels, Dr. Lenz and/or such assistants as may be designated by him/her to administer dilating eye drops. The eye drops are necessary to diagnose my condition. We recommend a driver.

Initials

I consent to treatment at Tennessee River Eye Clinic and my consent remains effective until revoked in writing by me. You have the right at any time to discontinue services.

Initials

I authorize the release of any medical information necessary to process a claim on any insurance policy on file. I hereby assign to and authorize payment directly to Tennessee River Eye Clinic/Mark Kassels M.D./Jan Lenz O.D. of all benefits payable under Medicare, Medicaid or other insurance policy as well as any MEDIGAP Insurance. I understand that I am ultimately responsible for all charges, whether or not paid by my insurance. I also understand that, should I default on my account, all costs of attorney's fees, interest and cost of collections would be my responsibility.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature (patient or representative)

Date

Release of Information To Family/Friends Authorization

Only complete the name/dob/ssn/signature and date.

Patients Name

Date of Birth

SSN

I authorize Tennessee River Eye Clinic to release my information to the following individuals:

Add Additional Names

Signature (patient or representative)

Date

Witness signature

Date

Release of Medical Records to Physician Authorization

Only complete the name/dob/ssn/signature and date.

Patients Name

Date of Birth

SSN

I request that:

Doctor/Hospital/Facility Name

Address

City

State

Zip

Release my medical records to Tennessee River Eye Clinic for the purpose of continuity of medical care.

Patients signature

Date

Witness signature

Date

New Patient History

Blank answers will be recorded as no/negative in your electronic record.

Name

Date of Birth

What is your current eye problem?

List all allergies

Past Eye history

Other eye doctor(s)

Problems

Prior Eye Surgery

Current eye medicines:

Do you now or have you ever had...

If yes, please explain

Past Medical History

Primary Medical Doctor

Diabetes

Thyroid problems

High blood pressure

Stroke

COPD

Cancer

Arthritis

Family history

Family Member

If yes, packs/day

Patient Signature

Date

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