Please download, print and complete the New Patient Forms prior to coming to our office. Faxing or carrying your patient forms with you to your appointment will, minimize your time spent in our waiting room. Please read our Office Protocol Acknowledgment page
Print these pages New Patient Forms 2015 PDF (53 kb)
Glaucoma Associates of Texas Patient Information Sheet
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Patient’s Name |
Nickname |
Referring Physician |
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Address |
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City/State |
Zip |
Phone No. ( ) |
Phone No. (Day) ( ) |
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Sex (circle one)
Male Female |
Birth Date |
S.S. # |
Patient’s Employer |
Occupation |
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Employer’s Address |
Zip |
Phone No. ( ) |
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Marital Status (circle one)
Single Married Widowed Divorced |
Age |
Spouse’s Name |
Spouse’s Employer |
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Notify in case of emergency |
Address (street, city, state) |
Phone No. ( ) |
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Notify in case of emergency (Not in household) |
Address (street, city, state) |
Phone No. ( ) |
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Dou have Medicare? (circle one)
Yes No |
Medicare Number |
Do you have Medicaid? (circle one)
Yes No |
Medicaid Number |
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Do you have Texas Commission for the Blind? (circle one)
Yes No |
Counselor Name & City |
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Do you have Champus? (circle one)
Yes No |
If so, name of insured |
Policy No. |
S.S. # |
Status (circle one) Active Retired Deceased |
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Do you have HMO or PPO? (circle one)
Yes No |
If so, name of company |
Is pre-approval required? (circle one) Yes No |
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Address (street, city, state) |
Zip |
Contact Person |
Phone No. ( ) |
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Name of Insurance Company (Private) |
Policy No. |
Is pre-approval required? (circle one) Yes No |
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Name if insured |
Date of Birth of Insured |
S.S. # |
Patient’s relationship to insured |
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Address (street, city state, zip) |
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Name of Insurance Company (secondary) |
Person to contact |
Pre-approval required? (circle one)
Yes No |
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Name of insured |
Patient’s relationship to insured |
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Address (street, city, state, zip) |
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Is this a Worker’s Compensation Claim? (circle one) Yes No |
Date of Injury |
Contact person |
Phone No. ( ) |
I hereby authorize the Physician’s at GLAUCOMA ASSOCIATES OF TEXAS to perform such treatments to me as may be prescribed by any attending physician during any and all of my visits to GLAUCOMA ASSOCIATES OF TEXAS.
I understand that I am financially responsible for ALL charges arising from services rendered to me by GLAUCOMA ASSOCIATES OF TEXAS.
Patient’s Signature:
Date:
I AUTHORIZE GLAUCOMA ASSOCIATES OF TEXAS TO FILE ON ANY AND ALL INSURANCE FOR ANY CHARGES THAT I INCUR. I REQUEST THAT ALL PAYMENTS FROM ANY OF THESE INSURANCES TO BE MAILED DIRECTLY TO GLAUCOMA ASSOCIATES OF TEXAS. I AUTHORIZE ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO RELEASE TO THE HEALTH CARE FINANCING ADMINISTRATION AND IT’S AGENTS, OR INSURANCE COMPANY, ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS OR THE BENEFITS PAYABLE FOR RELATED SERVICES.
Patient’s Signature:
Date:
IT IS THE POLICY OF OUR OFFICE NOT TO TREAT MINORS WITHOUT THE CONSENT OF A PARENT OR LEGAL GUARDIAN. IF A WRITTEN ONE CANNOT BE OBTAINED, A PHONE CONSENT WILL BE REQUIRED.
Patient’s Signature:
Date:
WELCOME TO THE GLAUCOMA ASSOCIATES OF TEXAS 1
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Name: |
Date: |
Date of birth: |
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Address: |
Telephone #: |
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Referring physician: |
Telephone #: |
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Address: |
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Primary care physician: |
Telephone #: |
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Address: |
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MEDICAL, FAMILY & SOCIAL HISTORY: Please check the following as they apply to yourself (S) or to family members (F):
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S |
F |
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S |
F |
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S |
F |
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anemia |
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emphysema |
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arthritis |
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gout |
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kidney disease |
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asthma |
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heart attack |
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stroke |
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cancer |
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hepatitis |
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thyroid disease |
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diabetes |
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high blood pressure |
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vascular disease |
Cause of death of parents, siblings and children:
Please circle "yes" or "no". Explain any "yes" answers.
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Are you using non- prescription drugs? |
no |
yes, |
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Do you use street drugs? |
no |
yes, |
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Do you drink alcohol |
no |
yes, how much? |
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Do you smoke? |
no |
yes, how much? |
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Have you ever been exposed to the AIDS virus? |
no |
yes, |
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Have you ever had a sexually transmitted disease? |
no |
yes, |
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Do you get allergy shots? |
no |
yes, |
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Marital status: single, married, widowed, divorced, other |
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Work status: Current occupation: Previous occupation: Any known toxic exposure? no / yes |
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Living arrangements: home, apartment, nursing home, other |
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Live alone? yes / no Status: independent / need assistance |
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Education level: high school, college, post-graduate degree, other |
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Driving: |
Do you drive in the day? yes / no with difficulty? yes / no |
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Do you drive at night? yes / no with difficulty? yes / no |
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WELCOME TO THE GLAUCOMA ASSOCIATES OF TEXAS 2
Name:
Date:
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REVIEW OF SYSTEMS: If you are currently having any problems in the following areas, circle and explain (if necessary).
This form completed by:
CONSENT
TO THE USE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR TREATMENT, PAYMENT, HEALTH CARE OPERATIONS, AND AS OTHERWISE ALLOWED BY LAW
Glaucoma Associates of Texas (hereinafter referred to as “Glaucoma Associates”) will maintain a record of the care and services you receive at Glaucoma Associates. This consent only covers your protected health information created while you are a patient of Glaucoma Associates. Your protected health information pertains to your diagnosis and/or treatment at Glaucoma Associates, including but not limited to information concerning mental illness (except for psychotherapy notes), use of alcohol or drugs or communicable diseases such as Human Immunodeficiency Virus (“HIV”), and Acquired Immune Deficiency Syndrome (“AIDS”), laboratory test results, medical history, treatment progress or any other such related information.
By signing this form, you consent to Glaucoma Associates’ use and/or disclosure of protected health information about you for treatment, payment, health care operations and as otherwise allowed by law. Our Notice of Protected Health Information Practices provides information about how Glaucoma Associates and its physicians may use and/or disclose protected health information about you for treatment, payment, health care operations and as otherwise allowed by law. By signing this form, you also acknowledge that you have received a copy of Glaucoma Associates’ Notice of Protected Health Information Practices and an opportunity to review it before signing this consent.
Signature of Patient or Legal Representative Witness
Date
Copyright © 2003 Burford & Ryburn, L.L.P.
GLAUCOMA ASSOCIATES OF TEXAS
RONALD L. FELLMAN, M.D. DAVID G. GODFREY, M.D. OLUWATOSIN U. SMITH, M.D.
DAVINDER S. GROVER, M.D., M.P.H. MICHELLE R. BUTLER, M.D. Matthew Emanuel, MD
Patient Authorization To Release Protected Health Information
I authorize Glaucoma Associates of Texas to release protected health information to the individual (s) listed below for the purpose of assisting with my care and/or payment.
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Name |
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Relation |
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Phone Number |
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Name |
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Relation |
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Phone Number |
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Name |
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Relation |
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Phone Number |
Description of the information to be used or disclosed (check all that apply):
- Patient’s demographic information
- Patient’s medical information
- Patient’s billing information
- Appointment Status
I understand that this authorization will be in effect during the time period I am a patient at Glaucoma Associates of Texas.
I further understand that this authorization is voluntary and that my health care and the payment of my health care will not be affected if I do not sign this form.
I further understand that if the recipient authorized to receive the information is not a covered entity, e.g. insurance company or non-health care provider, the released information may no longer be protected by federal and state privacy regulations.
I further understand that I may revoke this authorization at any time by notifying Glaucoma Associates of Texas in writing at 10740 N. Central Expressway, Suite 300, Dallas, TX 75231. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.
Signature of Patient or Patient’s Representative Date
Printed name of Patient’s or Patient’s Representative
Relationship to Patient or Legal Authority
10740 N. CENTRAL EXPRESSWAY SUITE 300 DALLAS, TX 75231 (214) 360-0000 (800) 683-0386 FAX (214)360-0083
417 W. MAGNOLIA AVENUE FORT WORTH, TX 76104 (817) 923-2000 FAX (817) 923-6639
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