Are you interested in Laser Vision Correction/ LASIK? Yes / No

(1)

Peter J. Cornell, M.D. Stuart B. Stoll, M.D.

450 North Bedford Drive, Suite 101 Beverly Hills, CA 90210

P: (310) 274 – 9205 F: (310) 274 -7229 www.bhlasik.com

Name

Last First Middle

Date

Date of Birth Age_ Sex: Male /Female

Email SS#_ Driver’s License #

Address

Street City State Zip

Mobile # Home # Work # Ext

Occupation Employer Name of Spouse Phone #_

Emergency Contact (nearest relative) Relationship Mobile # Home # Work # Ext If referred, by whom

Primary Care Physician

Last First

Phone #

Fax # Are you under the age of 18? Yes / No – If yes, ask front desk for separate form to fill out

Are you interested in Laser Vision Correction/ LASIK? Yes / No

Do you have medical insurance? Yes / No Do you have vision insurance? Yes / No

Name of Primary Insurance Name of Card Holder Name of Secondary Insurance Name of Card Holder Name of Vision Insurance Name of Card Holder Who, other then yourself is responsible for your account?

Name Relationship_ D.O.B. Address

Is the billing address different from home address? Yes / No if yes, please list new address below;

Authorization to release: I hereby authorize the above doctor/doctors to furnish the insured’s insurance company all

information which said insurance company may request concerning my present claim.

Assignment of insurance benefits: I hereby assign to the doctor all money to which I am entitled to expense relative to the

services performed from time to time, but not to exceed my indebtedness to said doctor. It is understood that any money received from the above named insurance company over the above my indebtedness will be refunded to when my bill is paid in full. I understand I am financially responsible to said doctor for charges.

(2)

Eye History

Yes

No

Loss of vision, blurred vision Fluctuating vision

Distorted vision (halos) Loss of side vision Double vision Dryness

Mucous discharge

Redness, Sandy, Gritty feeling Itching, Burning

Foreign body sensation Excess tearing/watering Glare/light sensitivity Eye pain/soreness Infection of eye or lid Tired eyes

Crossed eyes, lazy eye Drooping eyelid

General/Constitutional

Yes

No

Fever Weight loss Allergic/Immunologic Chronic cough Dry throat/mouth Cardiovascular Respiratory problems Chronic bronchitis Gastrointestinal Genitourinary

Genitalia, Kidney, Bladder Muscle, Joint, Swelling Neurological Psychiatric Endocrine Hematological/Lymphatic Blood Lymph nodes questions.

Social History

Yes

No

Do you have visual difficulty driving during the day

Do you have visual difficulty driving at night?

Do you currently wear contact lenses? Have you ever tried wearing contact lenses?*

Do you currently wear glasses?* Do you smoke Cigarettes? Do you drink alcohol?

*If you answered YES to wearing contact lenses or glasses, how long have you been wearing your most recent

prescription?

List any surgeries (including eye surgeries) you have had:

Is there any other health problems/history we should know about?

Please list any known drug allergies:

Are you allergic to latex, tape, or iodine? (If yes, please circle) List any other: _

Please list any medications currently being used:

Pharmacy Information

Have you ever taken any of the following medications: (if yes, please circle). Flomax, Hytrin, Cardura, Uroxatral

Pharmacy name:

(3)

Notice of Privacy Practices

To our patients. This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and

how you can get access to your health information. This is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Our commitment to your privacy

Our practice is dedicated to maintaining the privacy of your health information. We are required by law to maintain the confidentiality of your health information.

We realize that these laws are complicated, but we must provide you with the following important information:

We may use and disclose your health information for purposes of treatment, payment or health care operations. Use and disclosure of your health information in certain special circumstances

The following circumstances may require us to use or disclose your health information:

1. To public health authorities and health oversight agencies that are authorized by law to collect information. 2. Lawsuits and similar proceedings in response to a court or administrative order.

3. If required to do so by a law enforcement official.

4. When necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. We will only make disclosures to a person or organization able to help prevent the threat.

5. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. 6. To federal officials for intelligence and national security activities authorized by law.

7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. 8. For Workers Compensation and similar programs.

Your rights regarding your health information

1. Communications. You can request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. We will accommodate reasonable requests.

2. You can request a restriction in our use or disclosure of your health information for treatment, payment, or healthcare operations. Additionally, you have the right to request that we restrict our disclosure of your health information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Peter J. Cornell, M.D. or Stuart B. Stoll, M.D. The office manager may be reached by calling 310 274-9205.

4. You may ask us to amend your health information if you believe it is incorrect or incomplete, and as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Peter J. Cornell, M.D. or Stuart B. Stoll, M.D. The office manager may be reached by calling 310 274-9205. You must provide us with a reason that supports your request for amendment.

5. Right to a copy of this notice. You are entitled to receive a copy of this Notice of Privacy Practices. You may ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact our front desk receptionist.

6. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Stuart B. Stoll, M.D. The office manager may be reached by calling 310 274-9205. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

7. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

(4)

To Our Patients:

Please read the attached “Notice of Privacy Practices” (laminated copy). Complete and return this page that will remain in your chart. If you would like a copy of the Notice of Privacy Practices, please ask the front desk staff.

I hereby acknowledge that I have been presented with a copy of the Notice of Privacy practices from Peter J. Cornell, M.D., Inc.

Signature Date

Name of Patient

Contact Number(s)

To respect your privacy, please tell us which of the following numbers we should call to communicate with you regarding Appointment Reminders, Lab Results, etc. List only the phone number, or numbers, you want us to call where we can leave messages if needed.

Home # Work #

Cell # Other #

Authorized Contact(s)

Please list those people with whom we may discuss your personal healthcare information (doctor, personal assistant, nurse, family members, friends, etc)

1. Name of contact Relationship

Phone # Can we leave a message?  Yes  No

(5)

Do you have a Vision Plan?

(Separate from your Medical Insurance)

Peter J Cornell, M.D. and Stuart B. Stoll, M.D. will bill your vision insurance. If a medical diagnosis is found, both your medical and vision insurance will be billed. The medical portion will be subject to co-pays,

deductibles, and coinsurances. Otherwise, only vision insurance will be billed.

If your exam is only “routine” for glasses and/or contacts, and you wish to have it covered under your vision insurance, you must inform the office of the vision insurance coverage when the exam is scheduled, because vision insurance requires prior authorization for the exam. Our office will bill the vision insurance for the exam and you may get your glasses or contacts through our office. If during the vision exam a medical condition is discovered, you will be notified by one of our staff members (technician, doctor, billing manager, or front desk). At this point, you will be given the option of rescheduling another exam under your medical insurance or having the medical and vision condition fully evaluated and treated on the same day, in which case we will then bill your medical insurance for the medical condition and your vision insurance for the vision exam.

Our Patients Responsibility:

- Check what’s covered and not covered by your vision and medical insurance

- Note the date of service on which you last used your vision insurance (vision insurance can only be used once every fiscal/calendar year)

- Give the office complete and accurate information (including full name, social security number, and date of birth of the primary subscriber on vision insurance)

- Know the cost of your care (co-payments, deductibles and coinsurance)

Calendar Year

If your vision insurance is based on a calendar year, then you are eligible for covered services every January through to December. (If services are obtained any time during the previous calendar year eg. 07/31/2008, the eligible date for service would be 01/01/2009)

Fiscal Year

If your vision insurance is based on a fiscal year, then you are eligible for covered services every 12 months to the day. (If services are obtained on 07/31/2008, the eligible date for service would be 07/31/2009)

(6)

Most insurance companies, including Medicare, do not pay for the refraction.

Refraction is the portion of the eye examination that measures your eyes for any

necessary prescriptions.

If you are a member of a PPO, Private or Medicare insurance, that has a contract with

our office, we will submit the medical portion of your examination to them. You are

responsible for any co-pay amount plus the refraction charge of $60.00.

In the event you have vision insurance, the refraction charge will be covered in full.

Please read the attached laminated copy of “Do you have a Vision Plan?”

If you would like a copy of “Do you have a Vision Plan?” form, please ask the front

desk staff.

Initial

Contact Lens Fitting and Evaluation

Contact lenses are a medical device dispensed only by a prescription from a licensed

eye care professional. Contact lens prescriptions expire after 1 year. Your contact

lenses must be fitted and evaluated on a yearly basis in order to renew your contact

lens prescription.

There is a fee for this service which can vary from $40-$200 depending upon the type

of contact lenses you wear and the complexity of your contact lens fitting/ evaluation.

This fee will be determined by your doctor at the time of your examination. This fitting

and evaluation may be a non-covered service with your medical health insurance or

vision plan, meaning that you may be responsible for the contact lens fitting and

evaluation fee.

Any questions about this fitting and evaluation fee can be directed to your doctor

during your examination.

(7)

For office use only:

Total Speed Score (Frequency + Severity) =

SPEED II Questionnaire

Name: ,

(Last) (First)

Date: _/ /

Date of Birth: / / Sex: M F (Circle)

Dry Eye Disease is the most frequent reason that patients visit eye doctors. We are concerned that you may be suffering with this condition as well. Therefore, we ask that you take a few moments and thoughtfully complete the questionnaire below.

Report the FREQUENCY of dry eye symptoms you are experiencing by checking Never, Sometimes, Often or Constant using the numbering system below:

0 = Never, 1 = Sometimes, 2 = Often, 3 = Constant

SYMPTOMS 0 1 2 3

Dryness, Grittiness or Scratchiness Soreness or Irritation

Burning or Watering Eye Fatigue

Report the SEVERITY of your symptoms using the ratings list below: 0 = No problems

1 = Tolerable – not perfect but not uncomfortable

2 = Uncomfortable – irritating but does not interfere with my day 3 = Bothersome – irritating and interferes with my day

4 = Intolerable – unable to perform my daily tasks

SYMPTOMS 0 1 2 3 4

Dryness, Grittiness or Scratchiness Soreness or Irritation

Burning or Watering Eye Fatigue

Please mark with an X if you have experienced symptoms:

1) Today 2) Within the last past 72 hours 3) Within past 3 months Do you use eye drops and/or ointment? YES NO (Circle)

If yes, which drops do you use?

Have you been told that you have blepharitis or have you been treated for a stye? Blepharitis YES NO (Circle)

Stye YES NO (Circle)

Do you have fluctuating vision problems? ( That can be corrected with blinking) Circle: Never Sometimes Frequently A Lot/Always