James A. Davies, MD, F.A.C.S

Transcription

1 655 Laguna Drive Carlsbad, CA Welcome to Davies Eye Center! 25 Years of Innovative Care Dr. James Davies, M.D. is the Medical Director of Davies Eye Center and Surgical Eye Care Center, located in Carlsbad. As a surgical pioneer, Dr. Davies has been recognized as the authority in the field of cataract and refractive surgery with experience in a wide range of procedures, such as Corneal and Anterior Segment Eye Surgery, Corneal Laser Refractive Surgery, LASIK, and James A. Davies, MD, F.A.C.S Our Mission Statement & Values We are dedicated to providing quality Opthalmic medical services in a caring and professional atmosphere. The entire team at Davies Eye Center is committed to service, innovation, and quality care, while serving the needs of the community. The Davies Eye Staff

2 GETTING TO KNOW YOU We'd like to help you get the most out of your first visit with Dr. Davies. Your time with him is valuable and we have a few suggestions to help you make the most of your visit. To begin with, we ask that you complete the New Patient Information forms included in this Welcome Package before you come in to see Dr. Davies for your first visit. Please make sure you: 1) Complete the New Patient Form 2) Complete the Patient Health History Form 3) List all of your current Medications and Allergies 4) Complete the Review of Systems to mark any current or ongoing symptoms you are experiencing 5) Read, initial, and sign the Patient Agreement Please bring the completed forms and all insurance cards with you to your first visit. If you have any questions or would like assistance in completing any of these forms mentioned above, please call and we'd be glad to help. Making the Most of Your First Appointment Talk about your medications Talk about serious problems Don't be afraid to ask questions Review our Educational Videos on topics like Cataracts, Advanced Laser Cataract Surgery, LASIK, Dry Eye Disease, or Refractive Surgeries directly from our website, Davies Eye Center Patient Education Davies Eye Center offers many educational programs to the community, most of which are free of charge. Classes cover many topics and are generally open to anyone who wishes to attend, whether they are Davies Eye Center patients or not. Additionally, we offer a select number of courses for specific medical conditions that require a referral from your primary care provider.

3 NEW PATIENT FORM PATIENT INFORMATION Patient Last Name: First: Middle Initial: DOB: Address: City: State: Zip: SSN: Cell Phone: ( ) Home Phone: ( ) Gender: Male Female Marital Status: Single Married Separated Divorced Widowed Race: Caucasian Asian American Indian/Alaska Native Black/African American Hawaiian/Pacific Islander Hispanic/Latino Other Unknown Preferred Language: Do you have a translator? Yes No Emergency Contact: Phone: ( ) Relationship to Patient: Yes, you may discuss my medical information with this person. ADDRESS: May we send you information by ? Yes No DOCTOR INFORMATION Primary Care Physician: Please send my exam notes to this Doctor Phone: ( ) Fax: ( ) Optometrist: Please send my exam notes to this Doctor Other Doctor: Phone: ( ) Fax: ( ) Please send my exam notes to this Doctor Phone: ( ) Fax: ( ) PHARMACY INFORMATION Preferred Pharmacy Name: Phone: ( ) Fax: ( ) Street Address: How did you hear about us? My Optometrist or other Doctor Name? Another Davies Eye Patient Name? REFERRAL SOURCES City: Internet Search Which website or What search words did you use? Health Fair or Eye Screening Location? Newsletter or Magazine Ad Which One? Radio.Which Station? Other Please describe: AUTHORIZATION I authorize DAVIES EYE CENTER to release my name in thanking the above named patient/friend/family member. I also authorize the release of any medical information necessary to process all claims, including Medigap, and the release of payment of medical benefits to my physician. AS A COURTESY TO ME, DAVIES EYE CENTER WILL BILL MY INSURANCE COMPANY. IF MY INSURANCE COMPANY HAS NOT PAID THE CLAIM FOR WHATEVER REASON, WITHIN 60 DAYS OF TREATMENT, I AGREE TO BE FINANCIALLY RESPONSIBLE FOR ALL CHARGES INCURRED. NOTE: Medicare and other insurance providers typically do not cover reactive testing/procedures. You may be required to pay out of pocket for these services. PATIENT SIGNATURE: DATE:

4 PATIENT HEALTH HISTORY PATIENT NAME: DOB: Date: SOCIAL HISTORY Smoking Status? Current Smoker Occasional Smoker Former smoker Never smoked Drink Alcohol? 3+ drinks per day 1-2 drinks per day Less than 1 drink per day None Patient feels safe at home? Yes No If No, please explain: FAMILY HISTORY Check ALL that apply: Blindness Diabetes Hypertension Cancer Glaucoma Macular Degeneration Cataracts Heart Disease Retinal Detachment Please check the following medical conditions that you CURRENTLY have: Anxiety Depression Leukemia Arthritis Diabetes - Insulin? Yes No Lung Cancer Asthma End Stage Renal Disease Lymphoma Atrial Fibrillation GERD Prostate Cancer BPH (prostate) Hearing Loss Radiation Treatment Bone Marrow Transplant Hepatitis Seizures Breast Cancer Hypertension (High Blood Pressure) Stroke Colon Cancer HIV/AIDS Hypothyroidism COPD Hypercholesterolemia Other (Please List): Coronary Artery Disease Hyperthyroidism None Apply SURGICAL HISTORY Check ALL that apply: Appendix (Appendectomy) Gallbladder Skin Bladder (Cystectomy) Heart Spleen Breast: Lumpectomy R / L Joint Replacement: Knee R / L Uterus (Hysterectomy) Mastectomy R / L Hip R / L Other (Please List): Reduction R / L Kidney Implants R / L Ovaries Colon Prostate None Apply OCULAR HISTORY Check ALL that apply: Allergic Conjunctivitis Dry Eyes Ocular Migraines Blepharitis Glasses Retinal Detachment Cataracts Glaucoma Retinal Tear Contact Lenses Macular Degeneration Strabismus Diabetic Retinopathy Narrow Angles Floaters None Apply OCULAR SURGERY Check ALL that apply: Blepharoplasty Eye Muscle Glaucoma Cataract Surgery Dates: LASIK/PRK: Retinal Right Eye: Right Eye: Corneal Transplant Left Eye: Left Eye: None Apply PATIENT INITIALS:

5 PATIENT HEALTH HISTORY MEDICATIONS Please list ALL medications you are currently taking with their dosages and frequency. Include any vitamins and supplements. PATIENT NAME: DOB: Date: MEDICATION NAME DOSAGE FREQUENCY ALLERGIES Please list any and all medications you are allergic to and the reactions MEDICATION/ANESTHESIA NAME REACTION PATIENT INITIALS:

6 REVIEW OF SYSTEMS Please respond based on current or ongoing symptoms you are experiencing. PATIENT NAME: DATE: NAME SYSTEM YES NO Poor Vision Eyes m m Eye Pain Eyes m m Tearing Eyes m m Redness Eyes m m Jaw Pain Eyes m m Scalp Tenderness Eyes m m Amaurosis Fugax (Fleeting Blindness) Eyes m m Loss of Vision Eyes m m Fever Constitutional/Symptom m m Chills Constitutional/Symptom m m Weight Loss Constitutional/Symptom m m Stuffy Nose ENT and Mouth m m Ear Ache ENT and Mouth m m Cough ENT and Mouth m m Dry Mouth ENT and Mouth m m High Blood Pressure Cardiovascular m m Rapid Heart Beat Cardiovascular m m Congestion Respiratory m m Wheezing Respiratory m m Shortness of Breath Respiratory m m Upset Stomach Gastrointestinal m m Diarrhea Gastrointestinal m m Constipation Gastrointestinal m m Burning on Urination Genitourinary m m Urinary Frequency Genitourinary m m Incontinence Genitourinary m m Joint Pain Musculoskeletal m m Stiffness Musculoskeletal m m Arthritis Musculoskeletal m m Rash Integumentary m m Changing Moles Integumentary m m Headache Neurological m m Seizure Neurological m m Stroke Neurological m m Paralysis Neurological m m Anxiety Psychiatric m m Depression Psychiatric m m Insomnia Psychiatric m m Diabetes Endocrine m m Thyroid Abnormalities Endocrine m m Bleeding Hematologic/Lymphatic m m Anemia Hematologic/Lymphatic m m Allergies Allergic/Immunologic m m Hay Fever Allergic/Immunologic m m Hives Allergic/Immunologic m m CONTINUED ON BACK

7 REVIEW OF SYSTEMS Please respond based on current or ongoing symptoms you are experiencing. PATIENT NAME: DATE: ALERTS YES NO Allergy to Adhesive m m Allergy to Lidocaine m m Artifical Heart Valve m m Artificial Joints within past 2 years m m Blood Thinners m m Defibrillator m m Flomax m m MRSA m m Narrow Angles m m Pacemaker m m Premedication Prior to Procedures m m Rapid Heart Beat with Epinephrine m m Pregnancy or Planning a Pregnancy m m Pseudoexfoliation Syndrome m m Steroid Responder m m West Africa: Travel or Contact m m Ebola Risk: Fever > = degrees (F)/38.0 degrees m m Ebola Risk: Resided or Traveled to Country with wide spread Ebola transimssion in the last 21 days m m Ebola Risk: Contact with an Ebola patient without proper protective equipment in the last 21 days m m Ebola Risk: Headaches, weakness, muscle pain, vomiting, diarrhea, abdominal pain, and/or hemorrhage m m CONTINUED FROM FRONT

8 PATIENT AGREEMENT Please initial before each item explaining your agreement with Davies Eye Center INITIAL 1. RELEASE OF INFORMATION: Davies Eye Center/Surgical Eye Care Center may disclose all or any part of my medical record and/or financial ledger to any entity which is or may be liable or under contract with Davies Eye Center/Surgical Eye Care Center for reimbursement of services rendered, and other services related to my continued medical care including, but not limited to: Insurance Carriers, Referring Physicians, Anesthesiologists and Transcription Agencies. 2. INSURANCE: I understand that Davies Eye Center/Surgical Eye Care Center will bill my insurance carrier as a courtesy to me. I understand that it is MY RESPONSIBILITY to verify that Davies Eye Center, James A. Davies, MD, and/or Surgical Eye Care Center is a contracted provider with my insurance carrier. If Davies Eye Center/Surgical Eye Care Center has no contract with my insurance carrier, either expressed or implied, I understand that I am individually obligated to pay the full charges of all services rendered to me by Davies Eye Center/Surgical Eye Care Center. 3. NON-COVERED SERVICES: I understand that Davies Eye Center/Surgical Eye Care Center contracts with health care service plans for items and services which are 'covered' by the health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or services which are determined by the health care service plans NOT to be covered. Examples of non-covered services include, but are not limited to, services not specified as being covered in the patient's contract with a health care service plan or in the benefit summary the health care service plan furnishes to the patient; and treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with Davies Eye Center/Surgical Eye Care Center to obtain necessary health care service plan authorizations FINANCIAL AGREEMENT: I agree that in return for the services provided to the patient by Davies Eye Center/Surgical Eye Care Center, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to Davies Eye Center/Surgical Eye Care Center for payment. If an account is sent to a collection agency or attorney for collection, I agree to pay collection expenses and reasonable attorney's fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged a service fee. Any benefits of any type under any policy of insurance insuring the patient or any other party liable to the patient is hereby assigned to Davies Eye Center/Surgical Eye Care Center. If co-payments and/or deductibles are designated by my insurance carrier or health plan, I agree to pay them to Davies Eye Center/Surgical Eye Care Center. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill. PRIVACY PLAN: I agree that I have been given the opportunity to read and receive a copy of the Davies Eye Center/Surgical Eye Care Center Notice of Privacy Practices. This practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPAA). I UNDERSTAND that I may request a copy of this assignment at any time. This assignment will remain in effect until revoked by me in writing. A copy of this assignment is to be considered as a valid original. Patient or Guardian* Name (Print) Patient or Guardian* Name (Signature) Date * If this authorization is signed by a Guardian or Personal Representative of the Patient, the Guardian or Personal Representative's authority is based on: (e.g., State Law, Court Order, Power of Attorney, etc.)

9 REFRACTION FEE $43.00 The refraction is the portion of your eye exam that measures your ability to see an object at a specific distance. From the exam chair you look through a phoropter toward an eye chart. The phoropter contains lenses of different strengths and types that can be moved into view. Our technicians or doctors will ask you which view is clearer as they place different lenses in front of the eye ( better one or two ). When you are able to read the chart clearest, the technician or doctor will make notes of the lenses used. The process takes time and patience due to the interaction required for the most accurate outcome. A refraction is not just for an eyeglass prescription, although a new prescription is often the product of the refraction. The refraction is a critical part of any examination. It helps the doctor determine whether your vision is reduced by a medical disease (such as cataracts, macular degeneration, etc). It also helps the doctor follow the progression of cataracts and other conditions. Refraction has always been a NON-COVERED service under the MEDICARE program. Medicare does differentiate between a medical refraction and refractions performed solely for the purpose of providing glasses. OTHER INSURANCE plans may vary depending on your individual benefit coverage. In our experience, unless you have vision benefit coverage on your insurance, it will probably NOT cover the cost of the refraction. Our practice will submit this charge to your insurance carrier on your behalf, but please be aware that if they do NOT pay for this portion of your exam, we will have to send a bill. If you KNOW your insurance carrier will not pay the charge we ask that you make payment at the time of service. We recommend you check with your insurance provider PRIOR to your exam to see if you have coverage. Patient Name: Signature: Date:

10 PATIENT NOTIFICATION SUMMARY OF PRIVACY PRACTICES Date of last revision: Effective date: Immediately This information is made available upon request by a patient. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create medical records about your health, our care for you, and the services and/or items we provide to you. By law, we are required to make sure that your protected heath information is kept private. How will we use or disclose your information? Here are a few examples: (For more detail please refer to the Notice of Privacy Practices) For medical treatment To obtain payment for our services in emergency situations For appointment & patient recall reminders To run our Practice more efficiently and To avert a serious threat to health or safety For organ and tissue donation For worker's compensation programs In response to certain requests arising out of lawsuits or other disputes For research If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our Office Manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint. You have certain rights regarding the information we maintain about you. These rights include: The right to inspect and copy The right to amend The right to an accounting of disclosures The right to request restrictions The right to a paper copy of this notice The right to request confidential communications

11 How to find us Las Flores Dr Street View Street View Jefferson St Jefferson St Laguna Dr From the I-5 Freeway 655 Laguna Drive Carlsbad, CA Exit Las Flores and head West Make a LEFT on Jefferson Street Make a RIGHT on Laguna Drive Davies Eye Center is on the left hand side just past Madison Street