WELCOME TO NORTHERN VIRGINIA DOCTORS OF OPTOMETRY

PATIENT FINANCIAL AND INSURANCE INFORMATION

PATIENT NAME: GENDER: MALE / FEMALE

(PLEASE PRINT) LAST NAME FIRST NAME MIDDLE INITIAL (PLEASE CIRCLE) DATE OF BIRTH(MM/DD/YYYY) / / SOCIAL SECURITY NUMBER(last four): ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE:( ) WORK PHONE:( ) CELL PHONE:( ) E MAIL ADDRESS: EMERGENCY CONTACT AND NUMBER: PERSON(S) WE CAN DISCUSS AND/OR RELEASE YOUR HEALTH INFORMATION TO: Self only Name(s) MAY WE LEAVE A VOICEMAIL/EMAIL ABOUT YOUR HEALTH INFORMATION: Yes No RACE (CHOOSE ONE): Asian Black White Native American Pacific Islander 2 or more Other ETHNICITY(CHOOSE ONE): Hispanic Not Hispanic Employer: Occupation:

A NOTE TO ALL OUR CONTACT LENS WEARERS

In most cases contact lenses are not considered “medically necessary” by insurance companies. Any test performed to determine or update a contact lens prescription may not be covered by insurance companies and will be the responsibility of the patient. VISION INSURANCE

NAME OF INSURANCE: ID#: SUBSCRIBER INFORMATION

NAME: DATE OF BIRTH: SS# (last four): RELATIONSHIP TO PATIENT: WORK PHONE:( ) PRIMARY MEDICAL INSURANCE

NAME OF INSURANCE: ID#: SUBSCRIBER INFORMATION

NAME: DATE OF BIRTH: SS# (last four): RELATIONSHIP TO PATIENT: WORK PHONE:( ) SECONDARY MEDICAL INSURANCE

NAME OF INSURANCE: ID#: SUBSCRIBER INFORMATION

NAME: DATE OF BIRTH: SS# (last four): RELATIONSHIP TO PATIENT: WORK PHONE:( ) Medical Release Authorization and Insurance Assignment: I, the undersigned authorize payment from my insurance company to be made to Northern Virginia Doctors of Optometry (NVDO) for covered services. I understand that I am responsible for obtaining any referrals needed before my appointment or I must pay for that visit. Regardless of my insurances status, I am ultimately responsible for the balance on my account. Should timely payments of this account not be made, I authorize NVDO to retain the services of an attorney and/or collection agency to assist with the collection of any outstanding balance. Any expenses incurred by such an action shall become an additional liability for which I am responsible. I certify that the information I have recorded with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, to my insurance company in order to determine insurance benefits to which I may be entitled, this authorization may be revoked by myself at any time in writing. I have reviewed a copy of Northern Virginia Doctors of Optometry notice of Privacy Policies PRINT NAME SIGNATURE DATE

WELCOME TO NORTHERN VIRGINIA DOCTORS OF OPTOMETRY

TODAY’S DATE:

PATIENT NAME: DOB: Preferred Language: English Spanish

Race: American Indian or Alaskan Native Black or African American Asian Native Hawaiian/ Other Pacific Islander Hispanic White PERSONAL EYE INFORMATION

We would like to thank the person who referred you to our office: How did you hear about us? Yellow pages Insurance Google Friend/ Co-worker/ Family: Name: . Other:

Date of Last Eye Examination: Doctor’s Name: So we may better serve your vision needs, please complete the questions below regarding your visit to our office:

Do you work on a computer? If so, how many hours a day? Your reason(s) for visiting our office today: (please check all applicable items) General check up Headaches Want contact lenses Laser vision consultation Light sensitivity Standard soft Lost or broken glasses Eyes water Disposable Want new eyeglasses Eyes itch Tinted/ colored Blurred distance vision Eyes feel dry Bifocal/ Multifocal Blurred intermediate vision Pain in eyes Gas permeable Blurred near vision Flashes of lights Other Night vision problems Floating spots in vision Double vision Eyes feel tired Contact Lens Questionnaire:

Are you wearing contact lenses today? Yes No

If yes, what type? Soft Rigid/ Gas Permeable

What type of solution do you use to clean and disinfect:

Have your worn contact lenses in the past? If so, please tell us why you quit Please mark those activities in which you participate: Tennis Basketball Skiing Football Dancing Woodworking Soccer Swimming Hunting Fishing Golf Rollerblading Biking Racquetball Walking Scuba Diving Reading Baseball Gardening Crafts Jogging Sewing Aerobics Musical Instrument SOCIAL HISTORY

Do you drive? YES NO

If yes, do you have visual difficulty when driving? NO YES (describe)

Have you ever used tobacco products? NO YES If yes, type/amount/how long:

Do you drink alcohol? NO YES If yes, type/amount/how long:

Do you use illegal drugs? NO YES If yes, type/amount/how long:

***PLEASE TURN THIS FORM OVER AND COMPLETE OTHER SIDE*** FAMILY HISTORY YES WHO? (Blood Relatives ONLY) YES WHO? Arthritis Blindness

Cancer Cataracts

Diabetes Crossed Eyes

Heart Disease Glaucoma

High Blood Pressure Macular

High Cholesterol Degeneration

Kidney Disease Retinal Detachment/

Disease

Lupus

Thyroid Disease

Lung Disease

PERSONAL MEDICAL HISTORY Date of Last Medical Exam: Name of Medical Doctor: Doctor’s Phone #: List any MEDICATIONS you take (including oral contraceptives, aspirin, over the counter medications and home remedies): Do you have any ALLERGIES

List all major surgeries, injuries and/ or hospitalizations you have had: GENERAL HEALTH ENDOCRINE SKIN

Height: None None

Weight: DiabetesType IType II Eczema

None When diagnosed: Rosacea

Weight loss/ gain: Last HbA1c Other

Fever Thyroid (specify): MUSCLE/ SKELETAL

Fatigue Other None

Pregnant GASTROINTESTINAL Arthritis:

Breast-feeding None Type:

Trauma Crohn's Disease Fibromyalgia

Other Colitis Ankylosing Spondylitis

OCULAR Acid reflux/ ulcer Other

Blindness Hepatitis NEUROLOGICAL

Cataracts Other None

Glaucoma GENITAL/ URINARY Multiple Sclerosis

Macular degeneration None Epilepsy

Retinal condition Urinary Tract Infection Tremors

Other Herpes Other

ALLERGIC/IMMUNOLOGIC Chlamydia PSYCHIATRIC

None Syphilis None

Lupus (SLE) Other Anxiety

Rheumatoid Arthritis EARS, NOSE, THROAT Depression Environmental Allergies None Bipolar

HIV Positive Runny Nose, Post Nasal Drip Schizophrenia Other Sinusitis Other

CARDIOVASCULAR Upper Respiratory Infection RESPIRATORY None Other None

High Blood Pressure HEMATOLOGIC/ LYMPHATIC Asthma

Heart Disease None Bronchitis

Cholesterol Anemia Emphysema

Vascular disease Leukemia Other

Other Other

Patient Signature: Date:

Doctor Reviewed: Date:

Northern Virginia Doctors of Optometry Patient Financial Policy Northern Virginia Doctors of Optometry (NVDO)is committed to providing you with the highest level of service and care.It is our goal to provide you with a clear understanding of our Patient Financial Policy.If you have questions or concerns about our fees,policies or your financial responsibilities please let us know.We are committed to assisting you in any way possible to ensure your experience with our practice is seamless and enjoyable.It is your responsibility to notify our practice of any demographic,insurance or policy changes at time of service so that we can perform our duties accurately. Co-pays

If you would like us to submit your visit to your insurance for payment,you will need to provide your insurance card at each visit.All co-payments and past due balances are due at time of service unless previous arrangements have been made with a billing coordinator.When performing medical testing,NVDO is considered a “specialist” when determining your co-pay fees.

Insurance Claims

NVDO files your claims on your behalf to insurance plans that we are in network with.In order to properly file to your insurance provider,you will need to provide NVDO with your current insurance information (vision Insurance, medical Insurance;primary and secondary.)You are responsible for any co-pays or percent of charges that your insurance plan does not cover for that date of service.If any balance remains after the insurance provider has processed your claim,this balance will be due upon your receipt of notification.Failure to provide correct insurance information,at the time of your appointment may result in full patient responsibility. Referrals

If your insurance plan requires a referral to see a specialist,it will be your responsibly to obtain a referral from your Primary Care Provider (PCP).If you do not have the required referral at the time of service,the practice reserves the right to reschedule your appointment or you will be responsible for the total cost of services rendered.

Request for Medical Records/Forms

Patients requesting their medical records will be charged a $10.00 search fee and $0.50 per page up to 50 pages and $0.25 over 50 pages but not to exceed $35.00 total. Doctors/Attorneys requesting copies of a patient's medical records will be subject to a flat fee of $35.00. Any forms,at your request,to be filled out by the doctor are subject to a flat $25.00 fee. Returned Checks

Any payment made by check that does not clear your bank account will result in a $25.00 returned check fee for insufficient funds.This fee will be added to your account for each returned check. Minors

For any patients who are minors,the parent(s)or guardian(s)are responsible for full payment and will receive the billing statements for any minors receiving services.A signed release to treat may be required for unaccompanied minors.

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Missed Appointments

NVDO requests that you keep your scheduled appointment,but we understand that life happens.Please allow at least a 24-hour notice if you need to cancel your appointment.Missed appointments are subject to a $25.00 No-Show fee.

Outstanding Balance Policy

It is our office policy to physically mail three statements to patients with outstanding balances.We will send a courtesy email if no payment is made after the third statement has been mailed.If payment still hasn’t been made to the account,we will make one attempt by phone to make payment arrangements.If no resolution is reached, then a pre-collection letter will be mailed and we require a response within one week.If no action is obtained,then we will turn your account over to our collection agency. If your account is turned over to our collection agency,you will be responsible for the initial balance in addition to a 12%collection fee of the initial balance.

Please provide the office with an approved email address and phone number that we can reach you at regarding financial concerns.This ensures that if for any reason you are not receiving statements in the mail,we can reach you by email or phone.

I give permission for NVDO to email me regarding my financial account. My email address is: I Decline to allow NVDO to email me regarding my financial account Please list the preferred number to be reached at

Home,Cell,Work (please circle one) I give Permission for NVDO to leave a message regarding my financial account I Decline to allow NVDO to leave message regarding my financial account Northern Virginia Doctors of Optometry appreciates you for choosing us to help manage your eyecare health.We strive to provide you with the utmost care.If you have any questions or need more clarification on any of the above policies,please do not hesitate to contact us. Your signature indicates that you have read,understand and agree with our policies and procedures.

Print Name /Date of Birth Print Name of Guardian:(if patient is a minor) Signature Date

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