Clinic Intake Form | Panama City Optometry

PATIENT INFORMATION

Last Name:

First Name:

MI:

Social Security Number:

Date of Birth:

U.S. Military Service (Select One):

None Currently Serving Discharged

Address:

City:

State:

Zip:

Country:

Home Phone:

Work Phone:

Cellphone:

Email:

Marital Status (Select One):

Single Married Widowed Separated Divorced

Primary Language Spoken:

Limited English

Patient’s Relationship to Responsible Party (Select one):

Self Spouse Natural Child Parent Foster Child Foster Parent

Gender (Select One):

Female Male Transgender Male/Female-to-Male Transgender Female/Male-to-Female Other Choose Not To Disclose

Sexual Orientation (Select One):

Choose Not To Disclose Lesbian or Gay Straight (not lesbian or gay) Bisexual Something Else Don’t Know

Are you a migrant/seasonal worker or a family member of a migrant/seasonal worker?

Yes No

What is your annual income?

$0-$14,580 $14,581-$18,225 $18,226-$21,870 $21,871-$25,515 $25,516-$29,160 $29,161 & UP

How many people (including you) does your income support?

Emergency Contact:

Phone:

Relationship to Patient:

RESPONSIBLE PARTY INFORMATION

(Enter name of person FINANCIALLY responsible for your account)

Last Name:

First Name:

MI:

Mailing Address:

City:

State:

Zip Code

Country:

Home Phone:

Work Phone:

Cell Phone:

Date of Birth:

Social Security Number:

INSURANCE COMPANY – INCLUDING MEDICAID

Primary Insurance:

ID#:

Group #:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Secondary Insurance:

ID#:

Group#:

Insurance Company Address:

Name of Insured:

Date of Birth:

Insured’s Employer:

Relationship to Responsible Party:

Self Spouse Natural Child Step Child Parent Foster Child Foster Parent

Assignment and Release:

I authorize my insurance benefits to be paid directly to PanCare Health. I also authorize PanCare Health to release any information required to processthis claim.

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

SIGNATURE:

DATE:

HEALTH HISTORY

Patient Name:

Reason for Today’s Visit:

If pregnant, due date:

Last Pap Smear:

Last Mammogram:

Number of Pregnancies:

Number of Births:

Birth Control Method:

None

Pill

Condoms

IUD

Shots

Tubal

Vasectomy

Other

If Other, please specify:

Allergies:

Medications:

Pharmacy Name:

Pharmacy Location:

Hospitalization/Surgeries:

COVID-19 Vaccination Dose Number:

None First Dose Second Dose Booster Dose

Booster Dose #

Dental Pain:

Yes No

If yes, explain:

FAMILY HISTORY

Check all that apply to you and your family:

Alcohol Abuse

Asthma

Cancer

Depression

Diabetes

Glaucoma

Heart Disease

High Blood Pressure

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform the doctors at the next appointment without fail.

Patient, Parent, or Guardian Signature:

Date:

Dental Provider Signature:

Date:

Medical Provider Signature:

Date:

Broken Appointment and Confirmation Policy Agreement

Initials:

We enforce the two (2) broken appointment policy meaning that after 2 broken appointments within a twelve (12) month period, we will no longer schedule that patient, any adult/child living in the same residence, or any adult responsible for a child’s medical/dental/behavioral health treatment for one year from the date of the second broken appointment.

It is the responsibility of the patient (or parent/guardian, in case of a child) to notify the clinic any time they will not be available for their appointment, at least 24 hours prior to the scheduled appointment.

As a patient of the medical/dental/behavioral health clinic it is your responsibility (or parent/guardian, in case of a child) to confirm your appointment. We make every effort to call and confirm your scheduled appointment the morning prior to the appointment. However, without confirmation from you, we will remove
your appointment from the schedule and consider it a broken appointment.

Please make sure that your phone number is correct on your file and if your phone number changes you must contact the medical/dental/behavioral clinic to advise us of the change or again, we may cancel your appointment resulting in a broken appointment if we are unable to reach you.

Release of Medical/Dental/Behavioral Health Information

Initials:

It is the provider’s responsibility to ensure that the provider-patient relationship is confidential. Under the requirements of the Health Insurance Portability and Accountability Act (HIPAA) we are not allowed to release any patient information without the patient’s consent. If you wish to have your medical/dental/behavioral health or billing information released to a family member, friend, or legal representative, you must sign this form. Signing this form will only give consent to release this information to the persons indicated below. This consent form will not allow PanCare Health to release any other information to these persons. You have the right to revoke this consent in writing.

I authorize/allow PanCare Health to release my medical/dental/behavioral health and/or billing information
to the following individual(s):

Name:

Relationship to Patient:

Name:

Relationship to Patient:

Name:

Relationship to Patient:

Notice of Privacy Practices/Patient Rights and Responsibilities

Initials:

I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this organization’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I also understand that the Patient Rights and Responsibilities are available for my review and that I have responsibilities regarding
my care.

I understand that:

I have the right to review this organization’s Notice of Privacy Practices prior to signing this acknowledgement;
I have the right to review the Patient Rights and Responsibilities prior to signing this acknowledgement;
This organization reserves the right to change these documents and that these documents are available to me upon request at my next visit, and on the organizations web site: www.pancarefl.org.

Consent for Treatment

Initials:

I hereby authorize PanCare Health, its facilities and treatment centers, its affiliated providers, dentists, dental hygienists, ARNPs, physician assistants, psychologists, social workers and other medical personnel to administer examinations and treatments as deemed medically necessary.

Non-Covered Insurance Services

Initials:

I understand that I am financially responsible for any charges not paid by the insurance and that the insurance is filed as a courtesy. I understand that the insurance co-pays are estimated and are not a
guarantee of benefits. I also confirm that I will pay for any charges that will be incurred due to having a non-covered service performed.

Advance Directives

Initials:

I understand that I have the right to have an advance directive.

I currently have an advance directive:

Living Will

Health Care Surrogate

Durable Power of Attorney for Health Care

I do not have or want an advance directive

I would like more information regarding advance directives

We encourage all patients to complete an advance directive, which allows you to state your preferences for medical treatments and to select an agent or person to make your health care decisions in case you are unable to do so or if you want someone else to make decisions for you. Further information on advance directives is available on our web site www.pancarefl.org.

If you already have an advance directive, please bring a copy with you at your next visit. Your advance directive will be placed in your medical record. However, PanCare is not set up to make a medical determination as to the cause of an emergent situation that may present and/or occur at any of our clinics. In the event of an emergent situation, our staff will call 911 and defer the advance directive protocol to the acute hospital setting.

Acknowledgement

I have initialed the Broken Appointment and Confirmation Policy Agreement, Release of Medical/Dental/Behavioral Health Information, Notice of Privacy Practices/Patient Rights and Responsibilities, Consent for Treatment, Non-Covered Insurance Services, and Advance Directives. By doing so I acknowledge that I have read all of the aforementioned statements and will abide by the same and if I do not this may disqualify me from receiving care from PanCare Health Medical/Dental Clinics.

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

Signature of Patient/Legal Representative:

Date:

Name of Patient/Legal Representative:

Sliding Fee Application

Name:

I, name stated above, am requesting to be considered for the sliding fee scale discount offered by PanCare Health. By filling out this form and returning it for processing, I am asserting that the facts contained within are true and correct to the best of my knowledge. I understand that if the information proves fraudulent, PanCare reserves the right to cancel my Sliding Fee Scale status and bill
me in full for all previous visits.

Current Income: Please provide ALL requested income verification for ALL household members with your paperwork. Your appointment will need to be rescheduled if you do not provide this with your packet.

Employer:

Employer’s Phone Number:

Monthly Income:

Spouse/Significant Other’s Employer:

Monthly Income:

Any other income, including any other working adults that live in the home:

List all people (including children) in your household:

Last Name, First Name:

Date of Birth:

Relationship:

Last Name, First Name:

Date of Birth:

Relationship:

Last Name, First Name:

Date of Birth:

Relationship:

Last Name, First Name:

Date of Birth:

Relationship:

Last Name, First Name:

Date of Birth:

Relationship:

Last Name, First Name:

Date of Birth:

Relationship:

Attachments

Copy of one (1) paycheck stub from all employed members of the household
Copy of current year income tax return
Copy of recent W2 form
Copy of food stamp EBT card or copy of eligibility letter
Proof of benefits/income from social security, disability, unemployment, child support, retirement, etc.

File attachments

Add file

Please upload a file

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

Signature of Patient/Legal Representative:

Date:

PanCare Representative’s Verification/Signature:

Date:

Your information will be encrypted.