We will be closed Wednesday, July 4th in observance of Independence Day.
We will be back in the office on Wednesday, July 5th. Have a safe and fun 4th of July!
 
We will be closed Monday, May 28th, 2018 in observance of Memorial day.
 
 


Demographics & Insurance Information
Office
Name
Birthdate
Address
City
State
Zip
Phone
Cell Phone
E-Mail
Last Eye Exam
Occupation
Employer
Referred By
Guardian (if applicable)
Emergency Contact
Emergency Contact Phone


Do you have vision insurance?
If yes, insurance carrier
Do you have health insurance?
If yes, insurance carrier
Do you have medicare?


Primary Care Physician
Primary Care Physician Phone
Primary Care Physician Address


Race
Ethnicity
Preferred Language
Preferred Communication


Assignment of Benefits

I request that payment of authorized Medicare or other assigned insurance be made directly to Hopkinton Eye Associates for any services rendered. I authorize this holder of medical information about me to release to CMS and agents and information to determine these benefits payable for related services.

I understand that I am responsible for any non-covered services

Signature, Type Your Name (Parent/guardian, if under age of 18)

Notice of Privacy Practices

I acknowledge that I have been offered a copy of the Notice of Privacy Practices.

Signature, Type Your Name (Parent/guardian, if under age of 18)

Contact Lens Fees Notice

Most insurance carriers will not cover procedures related to contact lenses unless they are “medically necessary”. Most contact lenses are for cosmetic purposes. Please ask us for a quote of these additional fees.


Screening Retinal Photos
To ensure the thoroughness of your eye exam, the doctors at Hopkinton Eye Associates recommend having digital retinal photos taken on all our patients.

The procedure consists of simply taking a digital photograph of the back part of each of your eyes (retina). This is not an X-Ray or ultrasound procedure, and the camera does not touch you. You will be able to view and go over these photos with your doctor immediately after they are taken

What parts of the eye can be seen in the photos?
The Optic Nerve, Macula, Arteries and Veins, Retina, Choroid

What diseases can be detected or monitored with dilation and photos?
Glaucoma, Macular Degeneration, Signs of Diabetes, Ocular Melanoma, Hypertension and Heart Disease, Drug induced Ocular manifestations, and many more...there are just too many to list.

Reason for this extra test:
These photos become permanent invaluable data in your record, and allow the doctors to evaluate any changes over time by comparing your baseline photos with future visits.

This screening is NOT covered by insurance, and requires an additional fee of $39 at the time of your visit.

You will have an opportunity to discuss this with your doctor during your exam. Please sign below to show that you have read and understood this explanation sheet.
I would like to have retinal photos taken at this time.

Signature, Type Your Name (Parent/guardian, if under age of 18)



MEDICAL HISTORY
List medications you take (including oral contraceptives, aspirin, over-the-counter medications, and home remedies)
List all allergies to medications

Indicate any of the following that you have had:

age-related macular degeneration
inflammatory disorder
cataract
strabismus
kerataconus
amblyopia
glaucoma suspect
glaucoma
surgery
retinal degeneration
retinal hole
retinal detachment
patching
eye injury


Are you pregnant?
Are you nursing?

Do you wear glasses?
If yes, how old is your present pair of lenses?

Do you wear contact lenses?
If yes, what brand?
Type of contact lenses:
Are they comfortable?

Family History
Please note any family history (parents, grandparents, siblings, children: living or deceased) for the following conditions:
Disease/Condition
Yes/No/Unknown?
Relationship
Thyroid Disease
Diabetes
Hypertension
Cancer
Strabismus
Cataract
Glaucoma Suspect
Amblyopia
Severe Myopia
Macular Degeneration
Retinal Detachment
Retinal Disease
Glaucoma
Severe Hyperopia
Other

Social History
This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.
I prefer to discuss my Social History information directly with the doctor.

Do you drive?
If yes, do you have visual difficulty when driving?
If yes, please describe:

Do you use tobacco products?
If yes, type/amount/how long

Are you a

Do you drink alcohol?
If yes, type/amount/how long

Do you use illegal drugs?
If yes, type/amount/how long

Review of Systems
Do you currently, or have you ever had, any problems in the following areas:

Eyes
Itching
Diplopia
Burning
Mattering
Loss of Vision
Photophobia
Red
Floaters
Loss of Sharpness
Flashes
Tearing
Other
Constitutional
Developmental Disorders
Cancer
Fatigue Syndrome
Other
Ear, Nose, Mouth, Throat
Sinusitus
Dry Mouth
Hearing Loss
Laryngitis
Other
Neurological
Epilepsy
Multiple Seizures
Tumor
Cerebral Palsy
Stroke/CVA
Migraine
Other
Psychiatric
Depression
Bipolar
Anxiety
Attention Deficit
Other
Vascular/Cardiovascular
Vascular Disease
Stroke
Heart Disease
High Blood Pressure
Congestive Heart Failure
Other
Respiratory
Cigarette Smoker
Bronchitis
COPD
Emphysema
Asthma
Sleep Apnea
Other
Gastrointestinal
Celiac Disease
Crohn’s Disease
Ulcer
Colitis
Acid Reflux
Other
Genitourinary
Kidney Disease
STD–Herpetic/Chlamydia
Prostate Disease/Cancer
Other
Musculoskeletal
Arthritis
Ankylosing Spondylitis
Fibromyalgia
Muscular Dystrophy
Osteoarthritis
Gout
Other
Integumentary
Herpes Simplex/Cold Sores
Herpes Zoster/Shingles
Rosacea
Psoriasis
Eczema
Other
Endocrine
Diabetes Type II
Thyroid Dysfunction
Hormonal Dysfunction
Diabetes Type I
Other
Hematologic/Lymphatic
Large Volume Blood Loss
Anemia
Ulcer
High Cholesterol
Other
Allergic/Immunologic
Environmental Allergies
Lupus
Rheumatoid Arthritis
Sjogrens Syndrome
Other

If you answered yes to any of the above, or have a condition not listed, please explain:



Financial Policy
Medfield/Hopkinton Eye Associates acknowledges that it is a privilege to provide eye care to your family. We would like to give the best care at a reasonable fee. In order to hold billing costs to a minimum we expect payment at the time services are rendered, unless prior arrangements have been made. In order to be able to continue to see our patients in a timely manner for urgent issues we will charge a $40 fee for appointments which are not cancelled 24 hours in advance.

As per your contract with your insurance company, at the time of service you are to:
1.
Present your insurance card and inform us of any vision plan.
2.
Be prepared to pay your co-payment/co-insurance as stipulated in your contract (found on the face of your insurance card). In most cases, no co-pay will be collected for preventative services. However, if additional issues are addressed during the visit, a copay will be required.
3.
Inform the office of any insurance, billing or contact (telephone/address) changes.
4.
Be prepared to pay any deductible as stipulated in your contract with your insurance company. It is your responsibility to check the status of your deductible with the insurance company. We are unable to do this for you since we are not privy to this information so please review this information prior to your visit.

For your convenience we accept MasterCard, Visa, Discover, Amex, checks or cash. If your check is returned for non-sufficient funds, the bank will debit your account for the amount of the check, plus any applicable fees and we will bill you a $25 service charge. The use of a check for payment is your acknowledgement of this policy.

If someone other than a parent brings your child for care, they must provide the above information and pay the appropriate charges on your behalf.

Signature, Type Your Name (Parent/guardian, if under age of 18)






 
Our Eye Doctors have earned the trust and respect of our patients for being dedicated to your vision and your eye health.
 
CONTACT US TODAY
Medfield Eye Associates (508) 359-4164
Hopkinton Eye Associates (508) 497-9500
 
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Hopkinton Eye Associates 77 West Main Street Hopkinton, MA 01748 Phone: (508) 497-9500
Medfield Eye Associates School House Park 6 West Mill Street - 1st floor Medfield, MA 02052 Phone: (508) 359-4164

Medfield Eye Associates and Hopkinton Eye Associates proudly serve Medfield and Hopkinton, MA and the surrounding areas of Ashland, Framingham, Holliston, Medway, Walpole, Norwood, Westwood, Dover, Sherborn, Franklin, Norfolk, Wrentham, Foxboro, Mansfield and Canton.

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