Patient Information Form Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Prefix First Middle Last Suffix Date of Birth MM slash DD slash YYYY Mailing Address Street Address Address Line 2 City State / Province / Region 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 Primary contact phone numberEmail address(Required) How would you like us to contact you? Phone Email Text Employment Status Employed FT Student Retired Self-employed Other OccupationPrimary Care PhysicianSpecialist PhysicianPharmacyHow did you hear about our office?Insurance Authorization and Assignment I hereby give authorization for payment of insurance benefits to be made directly to Vitelli Eye Care, LLC for services rendered. I understand that I am financially responsible for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections. I hereby authorize this healthcare provider to release all information necessary to secure the payment of benefits. I further agree that the photocopy of this agreement shall be as valid as the original and that I have read and understand the contents thereof. If you have Medicare for your insurance, only those procedures that can be billed with a medical code are covered. The diagnostic procedure the doctor uses to determine your eyeglass prescription is a routine procedure known as a “refraction.” Medicare requires this procedure to be billed to them but they do not cover it because it is a routine procedure. The refraction fee of $40.00 is due and payable on the date of your exam. In addition to your medical insurance which may or may not cover a routine eye examdo you have separate vision insurance which covers your eye examinations and possibly materials? Yes No NOTE: Separate vision insurance needs to be revealed at the time of your exam as billing is done on the same day that you are seen and cannot be redone once submitted. Consent(Required) I have read and agree to the above(Required)Signature(Required)Date MM slash DD slash YYYY For Contact Lens Wearers: Your Annual Contact Lens Evaluation Contact lenses are medical devices that can cause serious consequences, such as infection, inflammation, permanent damage and loss of vision if not fit and taken care of properly. Examining a contact lens patient takes additional time and expertise for which most insurance companies do not reimburse. For that reason, there are separate, additional charges for contact lens examinations that patients without contact lenses do not pay. Dr. Vitelli must verify that your eyes are responding well to contact lens wear, check the ocular surface for any adverse reactions and make sure the lenses are fitting properly and are the correct prescription for your eyes. This type of examination is necessary if you wish to continue wearing contacts. Once finalized, per MA state regulations, your prescription is valid for up to 1 year. This means you can purchase enough lenses to last for 12 months and no more. After 12 months, the prescription expires. Dr. Vitelli will not renew expired prescriptions without first making sure that your eyes are healthy enough to wear lenses. To avoid any inconvenience, make sure your annual examination is scheduled on time so that you do not run out of lenses before you are seen. If you wear contact lenses, this examination must be done annually, even if your insurance only allows for a 2-year examination interval. If for some reason, you require additional time or visits because there has been a change in the type of lenses you wear, there may be additional refitting fees. These cover any additional examination time and follow-up appointments that may be necessary to finalize a refit into another type of contact lens.Consent I have read and agree to the aboveSignatureDate MM slash DD slash YYYY For Patients under the age of 18Guardian NameDate of Birth MM slash DD slash YYYY Mailing Address (if different than patient) Street Address Address Line 2 City State / Province / Region 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 Primary TelephoneSecondary TelephoneRelationship to PatientMedical History QuestionnaireMedications (including over the counter and vitamins)Allergies (both environmental and to medications)Do you smoke? Previous smoker? Packs per day?Medical History Do you currently, or have you ever had problems in the past with the following areas:EYES Conditions Disease Lazy or crossed Surgery Other OtherConstitutional Symptoms Fever Weight Loss/Gain Other OtherIntegumentary Skin problems Other OtherNeurological Headaches Seizures Other OtherEndocrine Thyroid Diabetes Other OtherEars, Nose and Throat Allergies Sinus Problems Other OtherRespiratory Asthma COPD Other OtherCardiovascular High Blood Pressure High Cholesterol Other OtherGastrointestinal Gastric reflux Other OtherMusculoskeletal Arthritis Muscle pain Joint Pain Other OtherLymphatic/Hematologic Anemia Bleeding problems Other OtherAllergic/Immunologic Auto-immune Other OtherPsychiatric Depression Anxiety Other OtherAre you currently pregnant or breast feeding?Family HistoryBlindness Yes No Relationship to youGlaucoma Yes No Relationship to youMac Degeneration Yes No Relationship to youRetinal Disease Yes No Relationship to youCrossed/Lazy eyes Yes No Relationship to youDiabetes Yes No Relationship to youOtherRelationship to youThe Difference between Health/Medical and Routine/Vision Insurance Periodic eye exams are important to maintain clear vision and healthy eyes throughout your lifetime. It is important that you understand your insurance benefits and how they apply to your visit. This sheet will help you understand how your visit will be submitted to your health insurance or vision plan. Benefits may vary based upon the reason for your visit, and your individual health insurance or vision plan. Routine Eye Examinations: A “routine” eye exam is performed to check the eye for visual deficiencies that would require glasses or contacts and to screen the eye for possible disease. It does not normally include a dilated retinal exam. This type of exam is covered by your Routine Coverage/Vision Insurance Plan. Examples include: Exam for new eyeglasses Exam for new contact lenses Medical Eye Examinations: Medical eye exams are for evaluation of a medical related complaint or follow up of an existing ocular condition found in a previous routine exam. Depending on the condition, dilation is often performed. This type of exam is billed to your Health/Medical Insurance Plan. Medical plans generally do not pay for the “refraction” (eyeglass prescription determination test) and you may be required to pay for this test. Examples that necessitate your visit being billed as a medical exam include but are not limited to: Diabetes Mellitus Floaters and or flashing lights Dry, Red, Allergic, Irritated, or Infection Glaucoma Macular Degeneration Cataracts Certain high risk medications If the doctor determines that your problem or exam falls under the category of a “medical eye exam,” your visit may be billed as a medical exam instead of a routine exam, and will be subject to co-pays and deductibles according to your medical insurance plan.Signature Δ
