PATIENT INFORMATION




   

All information provided by you is strictly confidential and will not be shared. The only information that is shared is the basic minimum required by your insurance company to pay your claim.

Section 1






              


Ethnicity

Race

Preferred Language




















Section 2

Emergency Contact Information


Responsible Party




Section 3



Section 4




 


 


AUTHORIZATION & ACKNOWLEDGEMENT

MEDICAL AUTHORIZATIONS AND RELEASE OF INFORMATION

I hereby authorize Louisiana Eye & Laser Center to furnish the insured’s insurance company all information which said insurance company may request concerning my present illness or injury. I hereby assign to the doctors all money to which I am entitled for medical and/or surgical expenses relative to the services performed. It is understood that any money received from the above named insurance company over and above my indebtedness will be refunded to me when my bill is paid in full. I understand that I am financially responsible for all charges, I hereby authorized Louisiana Eye & Laser Center to provide such medical services including surgery, if necessary, either regular or emergency, as may be determined to be in the best interest of the patient listed above. This authorization shall continue and remain effective until revoked in writing by me.


LIST ANY PERSON(S) TO WHOM YOU WILL ALLOW ACCESS OF YOUR MEDICAL AND BILLING RECORDS WHICH INCLUDES ANY DIAGNOSIS AND TREATMENT OF YOUR CONDITION.







AUTHORIZATION FOR RELEASE OF INFORMATION

The signature below serves as authorization for Louisiana Eye & Laser Center to release or receive medical information for the purpose of patient referral. A copy of this signature is as valid as the original.


ACKNOWLEDGEMENT

Refraction is the process of determining the eye’s refractive error, or need for corrective spectacle and/or contact lenses. It is an essential part of an eye examination, but is not a covered service by Medicare or most insurances. A fee of $35 for the refraction will collected in addition to any co-payment or deductible.

I have read the above information and understand that the refraction is a non-covered service. I accept full financial responsibility for the cost of this service. The co-payment is separate from and not included in the refraction fee.


ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

I have reviewed the Louisiana Eye & Laser Center Privacy Practice Notice that describes how information about me may be used and disclosed. At my request, I can receive a copy of this notice.

    

AUTHORIZATION OF DILATION

I hearby authorize the physician and/or such assistants as may be designated by him/her to administer dilating eye drops. I understand that these eye drops are necessary to diagnose my condition. I will need to wear sunglasses (available at checkout) due to sensitivity to light. More information about the drops and safety after dilation is available upon request.