EYE EXAM REPORT FOR INDIVIDUALIZED EDUCATION PROGRAM (IEP)
|
|
- Alexander Gilmore
- 6 years ago
- Views:
Transcription
1 Pg. 1-5 EYE EXAM REPORT FOR INDIVIDUALIZED EDUCATION PROGRAM (IEP) Instructions after doctor completes this form: Retain a copy in the patient file Fax to the attention of: Shawn Heimlich, Director of Special Services Or mail to: JA Special Services Office 6440 Kilbury-Huber Rd. Plain City, OH Doctor, please note NA (not applicable) beside any item below that is not included in your routine examination. Name of Student Name of School Parent/Guardian DOB Grade Exam OBJECTIVE FINDINGS A. Visual Acuity At Distance At Near Without Rx: (R) 20/ (L) 20/ (R) 20/ (L) 20/ With Old Rx: With New Rx: No Rx B. Cover Test Distance Old Rx New Rx Near C. Binocular Status/Efficiency Add remarks when ABNORMAL is checked. Near point of convergence Ocular motility (eye movement accuracy: ductions/versions Ability to maintain focus at near (amplitude) Binocular alignment distance (eye teaming at near) Binocular alignment near (eye teaming at near) Binocular depth perception (stereopsis)
2 Pg. 2-5 D. Color Perception DIAGNOSIS Convergence problems (R) (L) Accommodation problems (R) (L) Amblyopia Diagnosis (R) (L) Refractive Diagnosis Myopia (nearsighted) (R) (L) Hyperopia (farsighted) (R) (L) Astigmatism (R) (L) Emmetropia (no correction) (R) (L) NONE Ocular Health Diagnosis ---External Exam Diagnosis ---Fundus Exam Diagnosis Binocular Diagnosis Diagnosis Add remarks when ABNORMAL is checked Recommendations/Recommended Treatment No treatment indicated Present corrective lenses are satisfactory New corrective lenses have been recommended Remarks: A program of amblyopia treatment has been implemented Eye drops (R) (L) Patching (R) (L) Other Explain:
3 Remarks: Pg. 3-5 Return to this office for further care on (date) Further evaluation? (if yes, indicate what additional care is needed) CORRECTIVE LENSES SHOULD BE WORN Constantly Near Only Desk Work Computer Classroom Distance Only Sports Remarks: Special Recommendations for Classroom Interaction Please check which applies O.D. D.O. Signature M.D. Eye Care Provider Address Phone Instructions after doctor completes this form: Retain a copy in the patient file Fax to the attention of: Shawn Heimlich, Director of Special Services Or mail to: JA Special Services Office 6440 Killbury-Huber Rd. Plain City, OH 43064
4 Pg. 4-5 HIPPA INFORMATION RELEASE FORM As parent or guardian of the student named above, I authorize the eye care provider list to disclose (by mail or by facsimile) the results of the HB95 Eye Exam Report for IEP to my child s school: School Address City State Zip Phone Fax The purpose of disclosing the Eye Exam Report is for use in connection with my child s Individualized Education Plan (IEP). I understand that while in possession of authorized school personnel, the Eye Exam Report is not covered by HIPPA. Instead, it is an education record, whose privacy, use and disclosure is protected by the Family Educational Rights and Privacy Act. (FERPA) I understand that my refusal to sign the Authorization will not affect my child s ability to obtain treatment from the eye care provider listed above. I understand my right to inspect or copy information disclosed by this Authorization. I understand I may revoke (cancel) this authorization at any time. Revocation must be in writing. The eye care provider cannot be held responsible for having disclosed information in reliance of this Authorization before receiving a written revocation. I release the eye care provider from legal liability for disclosing The Eye Exam Report (and Protected Health Information contained in it) as authorized by my signature below. This Authorization will expire on: Or Event Signature of Parent or Guardian Print Name
5 Pg. 5-5 EYE EXAM PORTION OF HB 95 Section (A) In the and school years, within three Pg. months 4-5 after a student identified with disabilities begins receiving services for the first time under an individualized education programs, as defined in section of the Revised Code, the school district in which that student is enrolled shall require the student to undergo a comprehensive eye examination performed either by an optometrist licensed under Chapter of the Revised Code or by a physician authorized under Chapter of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery who is comprehensively trained and educated in the treatment of the human eye, eye disease, or comprehensive vision services, unless the student underwent such an examination within the nine-month period immediately prior to being identified with disabilities. However, no student who has not undergone the eye examination required under this section shall be prohibited from initiating, receiving, or continuing to receive services prescribed in the student s individualized education program. (B) The superintendent of each school district or the superintendent s designee may determine fulfillment of the requirement prescribed in division (A) of this section based on any special circumstances of the student, the student s parent, guardian or family that may prevent the student from undergoing the eye examination prior to beginning special education services. (C) Except for a student who may be entitled to a comprehensive eye examination in the identification of the student s disabilities, in the development of the student s individualized education program, or as a related service under the student s individualized education program, neither the state nor any school district shall be responsible for paying for the eye examination required by this section. District Designee s Signature Parent/Guardian Signature Cc: Student File Parent/Guardian Multifactor Evaluation
6
School Manual Statewide Vision Program School Year
601 Southwest 8 th Avenue Phone: (305) 856-9830 Fax: (305) 856-9840 School Manual 2011-2012 School Year Approved by: Ed Largespada, CFO Signature: Date: Phone: (305) 856-9830 / 1(888) 996-9847 Fax: (305)
More informationWelcome to the office of JillAnne W. McCarty, MD, PhD. We are looking forward to meeting you.
Welcome to the office of JillAnne W. McCarty, MD, PhD. We are looking forward to meeting you. For your convenience, attached are forms for you to fill out and bring to your visit. Information on our general
More informationCHILDREN S SPECTACLE SUBSIDY
How do I claim the All optometrists and ophthalmologists registered with Enable New Zealand have the required forms you will need to sign. On your behalf, the optometrist or ophthalmologist will submit
More information(PLEASE PRINT) Sex M F Age Birthdate Single Married Widowed Separated Divorced. Business Address Business Phone Cell Phone
(PLEASE PRINT) Emma Warner, MSW, LCSW, ACSW Tulsa, OK 74105 (918) 749-6935 Personal Information Name Address Last Name First Name Initial Home Phone Soc. Sec. # City State Zip Sex M F Age Birthdate Single
More informationHesch Institute. Dr. Jerry Hesch, PT, MHS, PT, E. Maple Place Phone: (303) am-5pm MST FAX: (303)
Dr. Jerry Hesch, PT, MHS, PT, 25837 E. Maple Place www.heschinstitute.com Aurora, Colorado 80018 Email: info@heschinstitute.com Phone: (303) 366-9445 8am-5pm MST FAX: (303) 366-9998 To Colorado Hesch Institute
More informationWarfighter Refractive Eye Clinic Womack Army Medical Center Fort Bragg, NC 28310
Warfighter Refractive Eye Clinic Womack Army Medical Center Fort Bragg, NC 28310 Complete packet provided by the Refractive Eye Clinic, WAMC, 2 South (2S). Commander s Endorsement Required (example enclosed
More informationStepping Stones Early Intervention Program 19 Harrison Avenue Roseland, NJ Phone: x1223
Stepping Stones Early Intervention Program 19 Harrison Avenue Roseland, NJ 07068 Phone: 973-535-1181 x1223 Dear Parents/Guardians: Welcome to the 2018-2019 Stepping Stones Early Intervention Program. Each
More informationAssociated Pediatric Dentistry Belleville, Edwardsville, O Fallon, IL
Associated Pediatric Dentistry Belleville, Edwardsville, O Fallon, IL Patient Name: DOB: ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT **You May Refuse to Sign This Consent Acknowledgement**
More informationHesch Institute Jerry Hesch, MHS, PT, DPT(s)
Jerry Hesch, MHS, PT, DPT(s) 1609 Silver Slipper Avenue www.heschinstitute.com Las Vegas, Nevada 89002 email: HeschInstitute@yahoo.com Phone: (702) 558-6011 8am-5pm PST (702) 565-6027 fax To future Out-of-Town
More informationApproved Version June
HEALTH PROFESSIONS COUNCIL OF SOUTH AFRICA GUIDELINES FOR MOBILE PRACTICE Approved Version PROFESSIONAL BOARD FOR OPTOMETRY AND DISPENSING OPTICIANS Original Issued: June 2017 Frequency of Review Responsible
More informationWritten Financial Policy
2316 South Mason Road Katy, TX 77450 Written Financial Policy Thank you for choosing Cinco Ranch Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important
More informationSouthwest Medical Thermal Imaging & Ultrasound, LLC. Informed Consent for Thermal Imaging. Patient Name: DOB:
Southwest Medical Thermal Imaging & Ultrasound, LLC Informed Consent for Thermal Imaging Patient Name: DOB: You or your physician have requested that we perform a Thermal Imaging scan to obtain additional
More informationPatient Instructions to Obtain Copies of Medical Records
Patient Instructions to Obtain Copies of Medical Records Thank you for allowing Ventura Orthopedics (VO) the opportunity to be your healthcare provider. Please review the following guidelines and instructions
More informationDr. Kinsler & Associates, LLC Help when life hurts
Dr. Kinsler & Associates, LLC Help when life hurts PREMARITAL COUNSELING INTAKE Bride s Name: WEDDING DATE: Age: Birthdate: Birthplace: Address: City: State: Zip: Phone: Highest level of education (grade/degree):
More informationSignature (Patient or Legal Guardian): Date:
X-Ray Patient Information: [ ] Male [ ] Female Patient Name: Date of Birth: / / SS#: Mailing Address: City: State: Zip: Phone # s: (Home) (Work) (Cell) Referring Physician: Phone #: /Fax#: Additional Physician:
More informationPatient Privacy Requirements Beyond HIPAA
Patient Privacy Requirements Beyond HIPAA Jane Hyatt Thorpe, J.D. School of Public Health and Health Services George Washington University Carrie Bill, J.D. Feldesman Tucker Leifer Fidell LLP The George
More informationDEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES DIVISION OREGON ADMINISTRATIVE RULES CHAPTER 411 DIVISION 58
DEPARTMENT OF HUMAN SERVICES AGING AND PEOPLE WITH DISABILITIES DIVISION OREGON ADMINISTRATIVE RULES 411-058-0000 Definitions CHAPTER 411 DIVISION 58 LONG TERM CARE REFERRAL SERVICES Unless the context
More informationNOTICE OF INFORMATION AND PRIVACY POLICIES FOR KAREN P. FREED, LCSW-C, BCD WHIPPOORWILL LANE NORTH BETHESDA, MARYLAND
NOTICE OF INFORMATION AND PRIVACY POLICIES FOR KAREN P. FREED, LCSW-C, BCD 12007 WHIPPOORWILL LANE NORTH BETHESDA, MARYLAND 20852 301-816-0978 THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED
More informationCINCINNATI CHILDREN S HOSPITAL MEDICAL CENTER CONSENT TO PARTICIPATE IN A RESEARCH STUDY
CINCINNATI CHILDREN S HOSPITAL MEDICAL CENTER CONSENT TO PARTICIPATE IN A RESEARCH STUDY STUDY TITLE: The International Diffuse Intrinsic Pontine Glioma (DIPG) Registry and Repository SPONSOR NAME: Maryam
More informationNew Patient Paperwork
Your Vision Is Our Focus New Patient Paperwork Dear Patient, Please fill out all of the following pages, and bring them with you to your scheduled appointment time. If you have questions regarding your
More informationSample Position Description
Sample Position Description Ophthalmic Assistant Job Title/Pay Grade Job Responsibilities Make introductions and establish rapport with patients. Initiate patient evaluation, documenting the chief complaint,
More informationChange. 50 Patients per day. Average Practice. Economics 7/11/2013
Change 50 Patients per day Must decide what is right for you Consider that times have changed There will be more change in the future Efficiency Average Practice 1.2 Patients / Hour Average income per
More informationWelcome to Dentistry by Design!
Welcome to Dentistry by Design! Thank you for choosing our practice as your preferred dental care provider. We look forward to getting to know you and working to establish a long and trusted relationship
More informationPS CHIROPRACTIC PATIENT CASE HISTORY
PS CHIROPRACTIC PATIENT CASE HISTORY Personal Information Last Name First Name Middle Initial Address: City: State: Zip: Home Phone: - - Work Phone: - - Cell Phone: - - Date of Birth: age Social Security
More informationApplication Requirements to be considered for Approval:
338 Grapevine Hwy. Hurst, Texas 76054 phone: 817.503.1500 toll-free: 877.203.9111 fax: 817.503.1551 www.mhstx.org Application Requirements to be considered for Approval: Please print your answers using
More informationNortheast Kingdom Human Services Impaired Driver Rehabilitation Weekend Program
Northeast Kingdom Human Services Impaired Driver Rehabilitation Weekend Program Enclosed is the registration paperwork required for registration (State of Vermont Registration form, State of Vermont Release
More informationOutpatient Wellness Clinic
Outpatient Wellness Clinic Patient Name: Date of Birth: Address: Phone: Email: Emergency Contact: Relationship: Phone: What is the reason for the appointment? Who were you referred by? (Physician, agency/
More informationMEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB. Please answer the following questions about your current eye problems and medical history:
MEDICAL HISTORY QUESTIONNAIRE Last name First Name MI DOB Please answer the following questions about your current eye problems and medical history: 1. What problems are you CURRENTLY having with your
More informationwww.thelmmfund.org info.thelmmfund@gmail.com SCHOLARSHIP APPLICATION FORM To apply for a scholarship from The Lisa Michelle Memorial Fund, please fill out the application below and submit all required
More informationTHERAPY ATTENDANCE POLICY
! THERAPY ATTENDANCE POLICY The primary focus of Dynamic Strides Therapy, Inc. s ( DST ) therapy program (the Program ) is to help the Patient named below to achieve his/her goals for therapy. We strive
More informationUNIVERSITY OF ALABAMA AT BIRMINGHAM SCHOOL OF OPTOMETRY Preceptor Application Form
UNIVERSITY OF ALABAMA AT BIRMINGHAM SCHOOL OF OPTOMETRY Preceptor Application Form The information on this form will be used to determine program eligibility, site visit information and to assist students
More informationADVICE & GUIDELINES ON PROFESSIONAL CONDUCT FOR DISPENSING OPTICIANS
ADVICE & GUIDELINES ON PROFESSIONAL CONDUCT FOR DISPENSING OPTICIANS SECTION 3: CONTACT LENS PRACTICE Equipment 87. In order to comply with the guidelines above, practitioners engaged in contact lens practice
More informationOSAN YOUTH SPORTS COACH/VOLUNTEER APPLICATION
OSAN YOUTH SPORTS COACH/VOLUNTEER APPLICATION Last Name, First Name, MI: Personal Information Address: City: Zip Phone: Email: Alternate Phone: Alternate Email: Date of Birth: Active Duty Civilian Rank:
More informationCALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION CDF (Page 1)
CALIFORNIA DEPARTMENT OF FORESTRY AND FIRE PROTECTION CDF 670 - (Page 1) VOLUNTEER IN PREVENTION APPLICATION AND SERVICE AGREEMENT CDF-670 NAME MALE HOME PHONE FEMALE WORK PHONE CITY/TOWN ZIP EMAIL SOCIAL
More informationOphthalmic Technician
Page 1 of 6 Job Title: Ophthalmic Technician Job Status: Non-Exempt Reports To: Clinic Coordinator/Ambulatory Services Manager Pay Grade: Department: Clinic Department Code: 400 Location: JOB SUMMARY It
More informationResidency in Vision Therapy and Rehabilitation & Pediatric Optometry
Residency in Vision Therapy and Rehabilitation & Pediatric Optometry Arkansas Vision Development Center Arkansas Vision Development Center 1021 South Waldron Road Fort Smith, AR 72903 Program Coordinator:
More informationPatient Questionnaire
Patient Questionnaire Name: Age: Date of Birth: / / Gender: M F Address: City: State: Zip: Telephone: Home: Work: Cell: E-mail: How did you hear about us? : In case of emergency, whom should we contact?
More informationPATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # HOME PHONE # CELL PHONE # WORK PHONE #
PATIENT INFORMATION PATIENT'S NAME DATE OF BIRTH SOCIAL SECURITY # STREET ADDRESS CITY, STATE, ZIP HOME PHONE # CELL PHONE # WORK PHONE # Emergency Contact & relationship: Phone #: Pharmacies local and
More informationInstructions for Completion of Medical Evaluation Requests
44-36 Vernon Boulevard, Long Island City, NY 11101 Telephone: (718) 392-8855 Instructions for Completion of Medical Evaluation Requests 2017-2018 Please read carefully and follow all instructions Incomplete
More informationSCHOOL MANUAL School Year
SCHOOL MANUAL 2017-2018 School Year Prepared by Program Manager Reviewed by CFO/Heiken Director Received by Program Coordinator Dannielle Dixson Richard Fernandez Received by Program Coordinator Received
More informationCreating a Successful MD/OD Business Model
Creating a Successful MD/OD Business Model JILL MAHER, MA, COE MAHER MEDICAL PRACTICE CONSULTING, LLC Objectives Challenges faced by Ophthalmology Practices What Can an Optometrist Bring to the Table?
More informationWelcome Letter- Orchard School Clinic
Welcome Letter- Orchard School Clinic Dear Parent or Guardian: Orchard School Clinic is a school-based location of RiverStone Health Clinic. This is a collaborative effort between RiverStone Health, Billings
More informationPROCEDURE-STUDENT RECORDS
PROCEDURE-STUDENT RECORDS 3600P This procedure specifies the management of student records by the District. These procedures are aligned with the Family Educational Rights and Privacy Act (FERPA). Type
More informationIf an optometrist rents space in which to practice optometry, the following requirements must be met:
DEPARTMENT OF REGULATORY AGENCIES State Board of Optometric Examiners OPTOMETRIC EXAMINERS RULES AND REGULATIONS 4 CCR 728-1 [Editor s Notes follow the text of the rules at the end of this CCR Document.]
More informationEmbracing Optometry & Vision Plans: Creating a Successful MD/OD Business Model Part I
Embracing Optometry & Vision Plans: Creating a Successful MD/OD Business Model Part I Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider
More information******************************************************************** Policy Expectation:
HIPAA Privacy Procedure #8 Effective Date: April 14, 2003 Reviewed Date: February, 2011 Use or Disclosure of Protected Health Revised Date: February, 2011 Information on Fundraising Scope: Radiation Oncology
More informationBuilding the Eye Care Team: Successfully Integrating an Optometrist to Create a Successful and Ethical MD/OD Practice Model
Building the Eye Care Team: Successfully Integrating an Optometrist to Create a Successful and Ethical MD/OD Practice Model JILL MAHER, MA, COE MAHER MEDICAL PRACTICE CONSULTING, LLC Disclosure I have
More informationWELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice.
WELCOME Those of us at Crossroads Counseling want to thank you for choosing to work with us and we want to make your time with us as productive as possible. In order to expedite the intake process, please
More informationCompliance Policy C-FMS Clinical Research Project Approval Application
Internal Use Only: Business Unit: Fresenius Medical Services Region: RVP: Area Manager: Facility # Compliance Policy C-FMS-009.2 of Investigator or Study Coordinator completes the following: Facility Name
More informationNPM INTAKE FORM. Home Phone No.: Work Phone No.: Cell Phone:
NPM INTAKE FORM INFORMATION: Name: Chosen Name (What would you like to be called?): Address: Date: Age: City/State/Zip: Home Phone No.: Work Phone No.: Cell Phone: Email Address: Date of Birth: Occupation:
More informationTotal Grace Achievers Academy Summer Camp Enrollment Application. Where kids can experience Life and Learn to Achieve
Total Grace Achievers Academy Summer Camp Enrollment Application Where kids can experience Life and Learn to Achieve Student Information Child s Name DOB Age Grade School: Street Address City State Zip
More information2017 VolunTEEN Scheduling Form. SHIRT SIZE: S M L XL XXL **sizes run big
2017 VolunTEEN Scheduling Form NAME: PHONE #: SHIRT SIZE: S M L XL XXL **sizes run big Indicate below your preference of shift by numbering the blocks by 1 st, 2 nd and 3 rd choice. If you have two first
More informationVOLUNTEER APPLICATION
VOLUNTEER APPLICATION Name: Age: Date of Birth: Social Security : Address: City: State: Zip Phone: Work: Cell: Email Address: How can we reach you? Home phone Cell phone Text Email Work phone Employer/School:
More informationPatient Registration Form
Padma Sripada MD, Columbia Internal Medicine 2500 Pond View, Suite 202 Castleton on Hudson, NY 12033 Phone: 518-391-2889 Date: Patient Registration Form First Name Middle Last Name... Sex: M F Preferred
More informationThe Role of the Receptionist, Technician, Doctor and Optician in Dispensing Eyewear
The Role of the Receptionist, Technician, Doctor and Optician in Dispensing Eyewear Peter Shaw-McMinn, O.D. Assistant Professor, Southern California College of Optometry Marshall B. Ketchum University
More informationPATIENT ADVOCATE DESIGNATION FOR MENTAL HEALTH TREATMENT NOTICE TO PATIENT
PATIENT ADVOCATE DESIGNATION FOR MENTAL HEALTH TREATMENT NOTICE TO PATIENT As the Patient you are using this Patient Advocate Designation for Mental Health Treatment to grant powers to another individual
More informationSchool Based Health Services Consent Form
MRN: PCP: Teacher: Grade: School Based Health Services Consent Form Before your child sees a provider, we are asking you to authorize medical and/ or dental treatment. We will work with you to improve
More informationHow do I know if I am eligible and how do I apply?
If you are unable to travel on the RIPTA fixed route bus service due to a disability, you may be eligible to use the RIde Program, a paratransit bus service. This allows you to schedule the specific bus
More informationWelcome to our office
Today s Date Welcome to our office Title Mr. Mrs. Ms. Miss Master Rev. Dr. PhD. Gender M F Last Name First Name Initial Name you would like to be called / Nickname Birthday Age Marital Status S M D W DP
More informationDischarge Planning for Patients Hospitalized for Mental Health Treatment Interpretative Guidelines for Oregon Hospitals
Discharge Planning for Patients Hospitalized for Mental Health Treatment Interpretative Guidelines for Oregon Hospitals May 2016 1 PURPOSE This document is meant to offer interpretative guidance for Oregon
More informationHow do I know if I am eligible and how do I apply?
If you are unable to travel on the RIPTA fixed route bus service due to a disability, you may be eligible to use the RIde Program, a paratransit bus service. This allows you to schedule the specific bus
More informationMedical History Form
Medical History Form Patient Name of Birth Medical History Do you have or have you had any of the following? Condition Yes No Condition Yes No Condition Yes No ADHD Stroke Menopausal Syndrome Allergies
More informationPre-Employment Physical Instructions
Pre-Employment Physical Instructions To schedule a Pre-Employment Exam, please call 928-774-3985. Your appointment will be located at Vera Whole Health, 1500 E Cedar Ave, Suite 80, Flagstaff, AZ 86004.
More informationForm B - For those enrolled in other insurance
Form B - For those enrolled in other insurance PATIENT REGISTRATION Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth
More information2018 Summer High School Volunteer Program. Required Forms. Please return the following four forms (with required signatures) by Wednesday, January 31:
2018 Summer High School Volunteer Program Required Forms Please return the following four forms (with required signatures) by Wednesday, January 31: 1. Recommendation Form #1 2. Recommendation Form #2
More informationPART B of Return Application Medical Documents
PART B of Return Application Medical Documents Durham, North Carolina Trinity College of Arts & Sciences/ Pratt School of Engineering HEALTH Recommendation for Readmission (please make as many copies as
More information(1) SHORT TITLE.--This section may be cited as the "Florida Patient's Bill of Rights and Responsibilities."
1 of 5 7/17/2008 3:37 PM Division of Medical Quality Assurance 381.026 Florida Patient's Bill of Rights and Responsibilities.-- (1) SHORT TITLE.--This section may be cited as the "Florida Patient's Bill
More informationTo provide an integrated and coordinated approach to delivering Newborn Metabolic Screening (NMS) Program services to all infants born in Alberta.
TITLE NEWBORN METABOLIC SCREENING PROGRAM DOCUMENT # HCS-32 APPROVAL LEVEL Alberta Health Services Executive SPONSOR Population and Public Health CATEGORY Health Care and Services INITIAL APPROVAL DATE
More information**IF YOU SHOW UP WITHOUT ANY OF THE LISTED ITEMS, WE WILL RESCHEDULE!!!**
Dr. Jasna Kojic 6000 Turkey Lake Rd. Suite 205 Orlando, FL 32819 PHONE: (407) 649-1848 FAX: (407) 649-1979 Dear Parent/Guardian of : We welcome you and your son/daughter to our office and are happy to
More informationCATARACT AND LASER CENTER, LLC
CATARACT AND LASER CENTER, LLC Patient Information Date: Patient Name: M F Address: Street City State Zip Home Phone: Work Phone: Cell Phone: E-Mail : Referred by: Medical Doctor: Who is your regular eye
More informationEnhancing the Patient Experience. Disclosures 3/13/2015. Jill Maher, MA, COE Senior Eye Care Business Advisor, Allergan, Inc Allergan Access
Enhancing the Patient Experience EXCELLENCE IN PRACTICE MANAGEMENT Embracing the Process of Effective and Patient Flow Jill Maher, MA, COE Senior Eye Care Business Advisor Disclosures Jill Maher, MA, COE
More informationPATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD
PATIENT REGISTRATION FORM PARENTAL MEDICAL CONSENT FORM FOR A MINOR CHILD General Consent for Treatment I have the legal right to consent to medical and surgical treatment because (a) I am the patient
More informationCATHERINE FUND FINANCIAL AID APPLICATION March 2016
GUIDELINES/ QUALIFICATIONS FOR Please read all Guidelines, Policies and Procedures, and Instructions before completing application. You must meet all guidelines for your application to be considered. 1.
More informationACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION CONSENT TO USE OR DISCLOSE MEDICAL INFORMATION
Patient Name (PLEASE PRINT): Date of Birth: ACKNOWLEDGEMENT OF HIPAA PRIVACY INFORMATION The & Center of Southern Oregon, PC s Notice of Privacy Practices contains information about the uses and disclosures
More informationDevelopmental Pediatrics of Central Jersey
PATIENT INFORMATION: CLIENT INFORMATION Date: Name: (Last) (First) (M.I.) Birthdate: Sex: Race: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email Address: Regarding the office staff or physician
More informationOPTICIANS REGULATION 118/2010
PDF Version [Printer-friendly - ideal for printing entire document] Published by Quickscribe Services Ltd. Updated To: [effective May 1, 2010] Important: Printing multiple copies of a statute or regulation
More informationThermography Welcome!
Revised: 10/15/2013 1 FULL BODY THERMOGRAPHY Thermography Welcome! Therrmography is a noninvasive imaging technique that is intended to measure temperature distribution of organs and tissues. The visual
More informationPsychology Laws and Rules Examination. FLORIDA DEPARTMENT OF HEALTH Division of Medical Quality Assurance. Computer-Based Test (CBT)
FLORIDA DEPARTMENT OF HEALTH Division of Medical Quality Assurance Application for Candidates Requesting Testing Accommodations in Accordance with the Americans with Disabilities Act Psychology Laws and
More informationPatient Name: Date of Birth:
: Patient Agreement Welcome to Community Psychiatry Community Psychiatry s dedicated providers and staff are committed to ensuring that each and every patient receives the highest quality psychiatry services
More informationJune%8,%2014. Dear%parent(s)%or%guardian,
June%8,%2014 Dear%parent(s)%or%guardian, My%name%is%Dr.%Nicholas%Port%and%I%am%a%professor%at%the%IU%School%of%Optometry.%%Along%with%my% colleague%at%optometry,%dr.%steve%hitzeman,%we%are%conducting%a%research%project%on%the%effects%of%
More informationPfizer Patient Assistance Program: Instructions for Group D Enrollment Form
Pfizer Patient Assistance Program: Instructions for Group D Enrollment Form This enrollment form is for patients who would like to apply to receive Lyrica (pregabalin) or Lyrica CR (pregabalin) extended
More informationTexas Higher Education oordinating oard Office of General ounsel P.O. ox 12788!ustin, TX
Student Information Name: Last First Middle Initial Address: City State Zip Phone: Date of Birth: Program of Study Email: at the Institution: Check the applicable box which describes your status with the
More informationAcknowledgement of Receipt of Notice of Privacy Practices
HIPAA PRIVACY FORM 2 Acknowledgement of Receipt of Notice of Privacy Practices Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good
More informationUse And Disclosure Of Protected Health Information (PHI) For Research
Current Status: Pending PolicyStat ID: 2558954 Origination: Last Approved: Last Revised: Next Review: Owner: Policy Area: References: Applicability: N/A N/A N/A 1 year after approval PAIGE ENGLISH: ASSOCIATE
More informationLou Eckart, Ph.D. and Associates Licensed Clinical Psychologists 22 Mill St. Suite 305 Arlington, MA
Lou Eckart, Ph.D. and Associates Licensed Clinical Psychologists 22 Mill St. Suite 305 Arlington, MA 02476 781-646-6306 Lou@Eckart-PhD.com PSYCHOLOGIST - PATIENT SERVICES AGREEMENT Welcome to our practice.
More informationDear Parent/Guardian:
Dear Parent/Guardian: Welcome to Indian Prairie School District. The purpose of this letter is to inform you of the health examination and immunization requirements in Illinois and the policy of the school
More informationPATIENT REGISTRATION FORM (ecw)
PATIENT INFORMATION PATIENT REGISTRATION FORM (ecw) (Please print) Patient s Name: (Last) (First) (MI) Address: City, State, Zip: Home: Cell: Work: E-Mail Address: DOB: Sex: Female Male Transgender Race:
More informationShould My 99 Year-Old Stepfather Be Allowed To Drive?
Should My 99 Year-Old Stepfather Be Allowed To Drive? Jerry and My Mom Michael G. Harris, OD, JD, MS Clinical Professor Emeritus UC Berkeley School Of Optometry Jerry s Vision & Health Concerns Jerry s
More informationMAIN STREET MEDICAL NEW PATIENT QUESTIONNAIRE
NEW PATIENT QUESTIONNAIRE Patient Name: Date: Date of Birth: SSN: Male Female Guarantor Name: SSN: DOB: Home Phone: Cell Phone: Street Address: Apt#: City: State: Zip: Billing Address (if different): Email
More informationPATIENT APPLICATION FOR TREATMENT
PATIENT APPLICATION FOR TREATMENT First Name: M.I.: Last Name: What do you prefer to be called: DOB: Age: Address: City: State: Zip Code: Home #: Cell#: Other: SS#: Sex: Single\Married\Divorced\Widow Spouse
More informationLalita Matta, MD Estrela Chaves, NP, CDE
PERSONAL INFORMATION Name of Patient: Maiden Name: Social Security No.: Date of Birth: Home Address: City: State: Zip: Home Phone: Mobile Phone: Work Phone: Email Address: Race/ Ethnicity: Marital Status:
More informationPlanned Respite Referral Application
Planned Respite Referral Application White Plains, NY 10605 (914) 948-4993 or (914) 564-3749 FAX: (914) 813-4364 Dear Applicant: Thank you for your interest in Planned Respite. Planned Respite is a short-term
More information~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT
~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document you
More informationNeedyMeds
NeedyMeds www.needymeds.org Find help with the cost of medicine Thank you for downloading this patient assistance document from NeedyMeds. We hope this program will help you get the medicine you need.
More informationSchool Based Oral Health Services
Seal a Smile Oral Health Program A project of Whitney M. Young Jr. Health Services and the Healthy Capital District Initiative School Based Oral Health Services Oral health classroom education Dental screenings
More informationLavaca SBHC Providers, Services, Hours, and How to Make an Appointment
The Lavaca School-Based Health Center (SBHC) is located on the Lavaca Middle School campus and serves all students and staff in our district, as well as community members. Our center offers medical, dental,
More information2018 SUMMER CAMP NANSEMA REGISTRATION NORTH SUBURBAN YMCA
2018 SUMMER CAMP NANSEMA REGISTRATION NORTH SUBURBAN YMCA CONTACT INFORMATION Camper s Name: Grade entering Fall 2018: Gender: Female Male Not specified DOB: Age as of 1st day of camp: Address: City: Zip
More informationInstructions for Completion of Medical Variance Requests
ALEXANDRA ROBINSON Executive Director 44-36 Vernon Boulevard, Long Island City, NY 11101 Telephone: (718) 392-8855 Instructions for Completion of Medical Variance Requests The application for an exception
More informationGENERAL CONSENT FORM TO THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
GENERAL CONSENT FORM TO THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I understand that VeinSolutions, a division of Cardiothoracic and Vascular Surgeons creates and maintains medical and related
More informationSt. Mary s Industrial Medicine 4017 Atlanta Hwy, Ste B Bogart, GA Phone: (706) Fax: (706)
Please Fill Out Completely: St. Mary s Industrial Medicine Patient s Last Name First Name MI Social Security Number Date of Birth Age Gender Race Marital Status Ethnicity (Circle one): Language Latino
More information