Patient information_shofner

PATIENT INFORMATION
Please complete all 4 pages and return to front desk upon arrival. Email address: _________________________________________________________ Mr/Mrs/Ms: _______________________________________ Date: ______________ Home Phone: ______________________ Work Phone: ________________________ Home Address: ________________________________________________________ City: __________________________________ ST: ________ Zip: ______________ Sex: ☐ M ☐ F
Marital Status: ☐ S ☐ M ☐ D ☐ W
Social Security#: ________ - ________ - ________ Date of Birth: _________________ Referred By: ___________________________________________________________ Family Physician: _______________________________________________________ Patientʼs Employment: ___________________________________________________ Employer: _________________________________ Phone: _____________________ Occupation: _____________________________________ Address: ______________________________________________________________ City: ____________________________________ ST: ______ Zip: ______________ Was this a work related injury? ☐ Yes ☐ No
Person responsible for this account: _________________________________________ Relationship to Patient: ____________________________Date of Birth: ____________ Social Security#: ________ - ________ - ________ Phone: _____________________ In case of emergency, who should be notified: ________________________________ Phone: _________________________ Relationship: __________________________ I authorize the release of any medical information to process all claims. I further authorize the
release of payment for medical benefits to Stewart Shofner, M.D., P.C.
Patientʼs Signature: _____________________________________________________ If you are here for laser refractive surgery, you are presently taking any of these
three medications: Imitrex, Accutane, or Cordarone? ☐ Yes ☐ No
PATIENT INFORMATION PAGE TWO
What is your chief complaint for todayʼs visit? _________________________________ ______________________________________________________________________ Do you have or ever had any of the following? List any medications you are currently taking (including eye drops) Do you or have you ever used prescription eye drops? Do you or have you ever worn contact lens? Are you or have you recently been pregnant? Have you recently suffered any heart disease? Do you have any allergies to any medications? If so, what? _______________________________________ List significant past medical history (eg. Eye Surgery, Eye Injury, and dates) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Comments: ____________________________________________________________ NOTICE OF PRIVACY PRACTICE ACKNOWLEDGMENT FORM
By my signature below, I am acknowledging I have received a copy of Dr. Stewart Shofnerʼs Notice of Privacy Practice concerning my protected healthcare information. __________________________________ __________________________________ Patientʼs Signature I authorize the following individuals to receive information about my health status, which may include information about my protected healthcare information. __________________________________ I understand Dr. Stewart Shofnerʼs office will only release my protected healthcare information to the individuals that I have indicated on this form. All other requests for protected healthcare information must be made in accordance with Dr. Stewart Shofnerʼs office HIPPA Policy and Procedure Manual concerning the privacy of my protected healthcare information. __________________________________ ____________________________ Patient Name (printed) __________________________________ Patientʼs Signature STEWART SHOFNER MD PC
FINANCIAL POLICY
We are doing everything possible to keep down the cost of medical care. The following is a summary of our payment policy. Please read this policy carefully, initial each paragraph, and sign at the bottom. ALL PAYMENT IS EXPECTED AT THE TIME OF SERVICE
________ Payment is required at the time services are rendered unless other arrangements have been
made in advance. This includes applicable coinsurance and copayments for participating insurance
companies. We accept cash, personal checks (in-state only), VISA, and MasterCard. There is a service
charge for returned checks. We would be pleased to process your application for Care Credit (it is a very
quick, simple process). We do not offer in house financing. Patients with an outstanding balance 60 days
or more overdue must make arrangements for payment prior to scheduling appointments. We realize that
financial difficulty is a reality and we will work with you to make sure you receive continued medically
necessary treatment.
INSURANCE
________ We bill participating insurance companies as a courtesy to you. You are expected to pay your
deductible and copayments at the time of service. If we have not received payment from your insurance
company within 45 days of the date of service, you may be expected to pay the balance in full. You are
responsible to be sure all charges are paid whether by you or by your insurance carrier. Over the past few
years, we have noticed a significant increase in the amount of our patientʼs deductibles and co pays. In
order to help make our services more affordable, we offer financing of copays and deductibles through
Care Credit. We would be pleased to process your application for Care Credit (it is a very quick, simply
process).
________ Patient/guarantor credits in amounts less than $20.00 will be retained on account to be
credited toward future balances unless a written request for refund is received. Amounts $20.00 and
greater will automatically be refunded to the patient/guarantor.
REQUIRED REFERALS
________ if you are enrolled in a managed care insurance plan (e.g. HMO), you must receive a referral from our office before seeing a specialist. Retroactive referrals are not guaranteed to provide insurance benefits. MISSED APPOINTMENTS/LATE CANCELLATIONS
________ Cancellations are requested 24 hours prior to the appointment. We reserve the right to charge
for missed, late, or cancelled appointments.
I have read and understood the Stewart Shofner, MD PC Financial Policy. I agree to assign insurance
benefits to the Stewart Shofner MD PC whenever necessary. I also agree that if it becomes necessary
to forward my account to a collection agency, in addition to the amount owed, I also will be responsible for
the fee charged by the collection agency for costs of collections.
Signature of insured or responsible party: _______________________________________________
Date: ____________________________

Source: http://www.shofnervisioncenter.com/documents/PATIENT%20INFORMATION_Shofner.pdf