Office Visit Form Office Visit Form Please complete the information below and submit the form online. This form contains confidential information and is delivered to your doctor through a secure Internet connection.Name: First Last Gender: Male Female Other Date of Birth: Month Day Year AgeAppointment With: Dr. Sutton Dr. Faiq No Preference Primary Medical Insurance: Medicare BCBS Care-First BCBS Aetna Cigna UHC UMR Tricare Prime Tricare Select PHCS KAISER Humana SELF PAY Other Notes:Secondary Medical Insurance: Medicare BCBS Care-First BCBS Aetna Cigna UHC UMR Tricare Prime Tricare Select PHCS KAISER Humana SELF PAY Other On a scale of 1-10, please rate your pain level:Please describe in depth the main problem you are currently having with your eyes (i.e. burning, watery, floaters, pressure feeling:When did the pain/problem first occur? (Exact date):Have you taken any over the counter drops or medicines to ease the pain/problem? If so, please list them below:Please list ALL medical problems:Please List ALL medications your taking:Please Provide your preferred pharmacy so the office can properly send prescriptions:Pharmacy Name:Location:Phone Number:HIPAA Agreement:(Required)I have read the terms and conditions of the Privacy Policy I Agree I DO NOT Agree Medical WaiverToday’s visit, and any follow up visits, will go through your Major Medical Insurance, not your Vision Plan, as the visit is not considered to be “routine”, it is medical. During your visit with the doctor today, there is a possibility a series of medical tests may need to be performed today or on an upcoming date such as a Visual Field, VEP (Visual Evoked Potential), ERG (Electroretinography) and/or an OCT scan. Your office visit today and any tests performed will be billed to your major medical insurance with the exception of your specialist copay. However, if you have not yet met your deductible or have an additional cost share, you will be held financially responsible for the remaining amount due after the claim has been processed. Please be advised that all balances due from insurance claims must be received within 90 days from date of billing or late fees will occur. By signing below, you acknowledge that the medical insurance information you have provided to us is correct and active and that any charges you may incur will be paid in full within the time frame allotted. Please be advised that it is the sole responsibility of the patient to know if your insurance does or does not require a referral for office visits and/or tests performed. If services are performed and a referral is required but was not obtained by the patient, the patient will be held liable for the total charge of the claim. If you are unsure about your plan, please ask a staff member to assist you before signing the form. Medical Waiver Agreement:(Required) I Agree I DO NOT Agree CAPTCHA Δ
