RECENT VISIT

Established Patient Form

PATIENT NAME:*
DATE:
Date Format: MM slash DD slash YYYY
PATIENT DATE OF BIRTH:*
OFFICE LOCATION:*
COVID-19 SCREENING
please read carefully
Have you or the patient traveled outside of New York/New Jersey/Connecticut for greater than 24 hours in the past 14 days?*
Is your or the patient’s temperature greater than 100°, off of fever reducing medications?*
Do you or the patient have a new onset or worsening of two or more of the COVID-19 symptoms (cough, shortness of breath, fever, chills, muscle pain, headache sore throat, new loss of taste or smell)?*
Are you or the patient under quarantine recommendations for any reason?*
Attestation: I understand the hazards of the novel coronavirus (“COVID-19”) and am familiar with the Centers for Disease Control and Prevention (“CDC”) guidelines regarding COVID-19. I acknowledge and understand that that the circumstances regarding COVID-19 are changing from day to day and that, accordingly, the CDC guidelines are regularly modified and updated and I accept full responsibility for familiarizing myself with the most recent updates.

I agree to adhere to Pediatric Ophthalmic Consultants (“The Practice”) guidelines and safety protocols. The Practice shall not be held responsible for any virus transmission regardless of the cause. I therefore release and hold harmless the Practice and its employees from all claims, damages and other liability arising from virus transmission.
Signature*
Patient or Patient’s Guarantor
PRINT NAME:*
PATIENT AND GUARANTORS RESPONSIBILITIES
please read carefully
*The cost of today’s ophthalmic medical exam is $350 for an established patient or $550 for a new patient (or for an exam occurring more than 5 years since prior exam here), unless a surgical procedure is also performed during the exam. Refraction, sensorimotor examination, ophthalmoscopy, and when needed ocular photos are necessary for a complete ophthalmic medical exam.
Initialing each section indicates your understanding of the following policies. If these responsibilities are not met, then you will be billed for the cost* of today’s visit.
Initial 00*
Initial Please:
- Please present the patient’s current, primary medical insurance card to our front desk. If a child is covered by two insurance plans, then the plan of the parent whose birthday occurs later in the year is considered secondary. If we do not have knowledge of the primary, active medical plan, then you will be responsible for the cost* of today’s visit.
Initial 01*
Initial Please:
- Please acquire referrals required by your medical insurance plan. If your plan requires a referral from the primary care physician for specialists office visits, then you will need an active referral for today’s visit. If you proceed to receive services in the absence of the required referral, then you will be responsible for the cost* of today’s visit.
Initial 02*
Initial Please:
- Please be aware of your medical deductibles. We do not participate with any “vision benefit” policies. Today’s visit will not be applied to your vision benefits or your routine eye benefits. Today’s costs will be processed through the patient’s medical benefits. If your in-network deductible has not been satisfied, then you will be responsible for part or all of the cost of today’s visit.
Initial 03*
Initial Please:
- Please be aware of your medical coverage. Our doctors are obligated to perform a REFRACTION upon all new patients and for most follow-up patients regardless of age and diagnosis. REFRACTION refers to the measurement of the focusing characteristics of the eye. Insurance companies now mandate that the REFRACTION procedure be charged separately from the rest of the eye exam. Some insurance companies do not pay specialists for the REFRACTION portion of the eye exam. If your insurance plan is one that NEVER covers this procedure, we will expect $45 in addition to the usual copay at the time of visit. If our submitted REFRACTION claim to your insurance company is uncovered, then you are responsible for the $45 REFRACTION fee.
Initial 04*
Initial Please:
- Please note that medical specialist copayments will be collected at the time of service. If you are unable to pay your copayment today, then a $10 administrative fee will be added to your costs.
Initial 05*
Initial Please:
- Please note our rescheduling policy. If you do not show for a scheduled appointment or cancel within less than 24 hours of the time of your scheduled appointment, then a $25 rescheduling fee will be added to your costs.
Initial 06*
Initial Please:
- Please acknowledge this guarantor agreement. By presenting my credit card to the receptionist at the front desk, I understand that it will be saved through a secure payment processing platform supported by Level 1 PCI Compliance. I authorize, without prior notification, eventual payment with said credit card for the amounts the provider is contractually obligated to collect including, but not limited to: copayments, co-insurance, deductibles and/or uncovered services.
Initial 07*
Initial Please:
I accept responsibility for and guarantee payment for any fees charged for the patient’s treatment, regardless of any insurance benefits the patient is entitled to, and assign the benefits payable for physician services to the physician.

I have read the notice of Privacy Practices. If I request a copy of today’s consult report, unless I indicate otherwise, this will be sent via email. Also a reminder for any follow up appointments may be sent via email unless I indicate otherwise. I also consent to permitting use of the patient’s photograph for medical education programs and medical publications. I agree that Pediatric Ophthalmic Consultants may request and use my prescription medication history from other healthcare providers or third party pharmacy benefit payors for treatment purposes.
SIGNATURE:*
Patient or Patient’s Guarantor
PRINT NAME:*
Would you like a copy of these forms emailed to you?
- YES
- NO
Please enter email address where you would like these forms sent.
CAPTCHA
Thank you for completing these forms on line. Required fields will be highlighted if missed. Once your forms are complete and successfully submitted a confirmation page will appear and copies will be emailed to the address entered.

Pediatric Ophthalmic Consultants

40 West 72nd Street, New York, NY 10023 | 212-981-9800

The content of this Web site is for informational purposes only. If you suspect that you or your child has any ocular problem,
please consult your pediatrician, family practitioner, or ophthalmologist to decide if a referral to a pediatric ophthalmologist is required.

Established Patient Form

COVID-19 SCREENING

PATIENT AND GUARANTORS RESPONSIBILITIES