new Paciente spanish form Nombre* First Last Fecha de Nacimiento* MM slash DD slash YYYY EdadPaciente Nuevo Anterior Address Street Address Address Line 2 Ciudad Estado ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country SS*Sexo Hombre Mujer Telefono Casa*Mobil/Trabajo*EmpleadorTelefonoEn caso de emergencia, ContactoTelefono#*Metado de pago para hoy Cash Check Visa MC Discover Cuando fue su ultimo examen para la vista? MM slash DD slash YYYY A usado lentes? Si No Par que los usa?DistanciaCercaTiene alguna alergia a los medicamentos Si No si la respuesta es si, por favor lista Usa Medicaciones regulamente? Si No si la respuesta es si, por favor lista Si usted tiene algunos de los siguentes problemas por favor de marcar lo Allergias Sinucitis Diabetes Asma Alta precsion de sangre Problemas del Corazon Sencilibidad a luz: Dolor en los ojos Le arden los ojos Picazon en los ojos Cansado los ojos Se le secan los ojos Dolores de cabez frequentesGlaucomaAlguna persona en la familia con glaucoma?Ha tenido usted:Infection do ojosLastimaduraCirujia de ojosAhora usa usted lentes de contacto?Ha usado antes lentes de contacto?Quiere usted usar lentes de contacto?De cual tipo esta usted interesado?Duerme consus lentes?Cuanto tiempo tiene con sus lentes?Cuales soluciones usaTiene alergia an alguna solution?Procedimientos para examines espciazles son disponible cuando son necesarios y se discutiran durante su examen. Examinaciones additionales requieren mas tiempo que el examen regularde vision y puede hacer cita para otra dia y tiempo. Las costas son variables: Examenes Visuales Computerizadados para Glaucoma, desordenes, Retinales, o Neurologicos Examen de pupilas dilatados para diabetes, myopes alta, trauma de cabeza, episodios de flotables, historia de probldmas de ojos familil o otros problemas Applanation Tonometrica para sospechosos de glaucoma Cuando compra lentes es la responsibilidad de el paciente de las reglas de la tienda. Es cortesia professional de la industria optica de no cobrarle al paciente para rehacer lentes y cambiar solamente el estilo de los lentes. Aun hay unos opticas chicos de descuento que se cobraran por estos servicios, es preferable que usted sepa de esto antes de comprar. En addition guarantias no se ofrecen por COD opticas, y eso le puede ahorar dinero por eso debe preguntar. Esta officina no pagara por agustamientos necesarios para sus lentes y tampoco por garantias.Firma*Fecha MM slash DD slash YYYY PATIENT CONSENT FORMI understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have certain rights regarding my protected health information. I understand that this information can and will be used to: Conduct. Plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. I have received read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at any time to obtain a current copy I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment or payment. I also understand you are not required to agree to requested restrictions, but if you do agree, then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient NameRelationship to PatientSignatureDate MM slash DD slash YYYY FINANCIAL RESPONSIBILITY STATEMENTWe will be happy to help you file your insurance claim forms or take assignment on your vision/medical benefit as designated by (name of insurance company)under (primary member’s name) This will be provided without additional charge to you. We will also do all that we can to help you receive maximum benefits. In the event that the Plan Sponsor determines that you are not eligible at the time of service, or makes a determination that you are eligible for a reduced level of coverage, by signing this statement you do hereby agree to be financially responsible for any deductibles, co-payments, and co-insurances incurred at the time of the visit. I understand that the nature of my eye appointment, ocular and medical history and ultimate diagnosis/es will be used to determine which medical and/ or vision plans will be billed. If left unsigned, you will be responsible for full payment of services rendered at the time of service at our usual and customary fee levels. I understand that if, for ANY REASON, payment for provided services and/or products is denied to Dr. A. Joshi & Associates, Optometrists, PA. by my third part insurance, I am responsible for payment of provided services and/or products that were denied by insurance and payment will be expected within 30 days of receipt of this bill Signature (Patient/Guarantor)Date MM slash DD slash YYYY Δ
