Neuro-Visual Rehab Consult Form

Welcome!
We look forward to seeing you for your Neuro-Visual Rehabilitation Eye Evaluation.

Please send medical and eye records prior to your appointment. Enclosed is a medical record release form for retrieving these documents. We prefer to review your medical and eye history prior to the appointment, including MRI or CT scan results, past therapy reports, and neurologic reports. Please include past eye exams. This will be helpful in planning your care and avoid duplication in testing. Please mail records to the St Joseph address, or have them faxed prior to your appointment. We are happy to see you for this specialized neurological eye exam to assess your visual abilities. The evaluation is split into the following 2

appointments:


1) The 1st assessment is a 1.5-2 hour initial assessment. Your eyes will be dilated.

2) The 2nd assessment is a 1.5-2 hour second assessment. Please dress comfortably, as there is a significant amount of balance and movement.

A full report will be sent to you following the 2nd visit. If you have any questions, please call our St Joseph office at (320) 433-4326. We look forward to being a part of your rehabilitation team.

Thank you,
The staff at Russell EyeCare & Associates

I authorize to release health information identifying me. Be aware that records released may include information regarding sexuallytransmitted diseases and mental health information. The records are released under the following terms/conditions:

1) Information to be released:


2) Who information is being released to:


3) Purpose of release: Continued care / Legal / Patient Record / Referral


4) This release expires 180 days after signed below

It is your decision to sign this form. If you sign this form, you can refused to revoke it at a later day, but we have already set it to automatically expire. To revoke prior to 180 days, please tell us that in a written note with your signature, and send to the address listed on the side of this form.

When your health information is disclosed, the recipient often has no legal duty to protect it’s confidentiality and may re-disclose it as they wish. Our office protects your information, we do NOT re-disclose it without your written consent.

I would like my information sent to the recipient via:

*Our office does not send or accept records via email, as this is an unsecured method. There is a $5.00 charge for mailing records. There is no charge for faxing records.*

I have read and understand this form. I am signing voluntarily. I authorize the disclosure of my health information as described above.

Date Signed

Signature

If the patient is under 18 or has a legal guardian, the legal guardian needs to sign. Describe your relationship to the patient and source of authority to sign the form.

Relationship to Patient:

Print Name:

Source of authority (guardian/parent/etc.):

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY
PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

(You may refuse to sign this form. In refusing, we will not be allowed to process your insurance claims.)

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy
Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. My signature will also serve as a PHI document release should I request treatment or imaging be sent to other attending doctors/ facilities in the future.
This HIPPA Form will serve as authorization until a new form is signed and replaces this form.

Signature of Patient or Legal Representative

Description of Authority

*You are normally address by first name only in the reception area. Please let us know if this is not how you would like to be addressed.**

Please list any individuals who can have access to your health information below:

Name

Relationship

Name

Relationship

Insurance Authorization Release
With the signature below, I authorize the release of any medical or other PHI necessary to process this claim and any future claims. I authorize payment of medical, eyeglass, or contact lens benefits to Russell EyeCare & Associates. (This replaces signatures for boxes 12 & 13 on CMS-1500 paper insurance forms, as RE&A files electronically.)

*I UNDERSTAND THAT I AM RESPONSIBLE TO KNOW MY INSURANCE BENEFITS AND
NETWORKS. I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY INSURANCE.*

Signature of Patient/ Guardian:

*We do not take the following eye care plans: VSP, EyeMed, Aetna Vision, United Healthcare Vision, BlueView, BlueVision, Optum, Spectera, Davis, or Superior Vision.*

I authorize contact from this office to confirm appointments, treatment, and billing information

Initials

I authorize contact from this office about special services, new health info or special patient events

Initials

Medication Reconciliation Authorization

I authorize Russell EyeCare & Associates to access any e-pharmacy database to perform a medication reconciliation, if needed. I also authorize the doctor to electronically send prescriptions to the pharmacy of my choice.

Signature of Patient/ Guardian: *

Name

Email Address

CC: What can we do for you today?

Do you use tobacco?

Do you use alcohol?


OPTOMAP RETINAL EXAM (circle yes or no)

At Russell EyeCare we pride ourselves on providing our patients with the best possible standard of care. Because of this, we now perform the Optomap Retinal Exam with all of our patients. This non-invasive procedure allows the doctor to see a much broader view of the retina and provides a baseline image to compare to future exams. This helps to detect ocular disease in patients young and old and is advised for patients over 4 years of age. The Optomap is an enhancement to the general eye exam and not covered by insurance.

I understand that the Optomap fee is $29, not covered by insurance, and is due at time of service.

DILATION
In order to assure the highest level of eye health examination, Dr. Russell STRONGLY ADVISES dilation of the eyes to check for ocular diseases that can cause blindness.
**Your vision may be blurry for 1-2 hours and some light sensitivity is normal. Please use caution while driving.**

“I understand my eyes will be dilated, and understand I should use extra caution while driving” *

HEALTH HISTORY


Last visit​​​​​​​


Have you EVER had a head injury?

Do you suffer from migraines or headaches?

ROS - Do you have any of the following symptoms? (If you do, CHECK the symptoms below.)​​​​​​​

AL/IM

CV​​​​​​​

CST

END

GI​​​​​​​

ENT​​​​​​​

MS​​​​​​​​​​​​​​

NEUR​​​​​​​

PSY​​​​​​​

RSP​​​​​​​

What medications or vitamins do you take (please list dosages)?

Does anyone in your FAMILY have any EYE or MEDICAL conditions?

CONTACT LENSES

Do you wear contacts?

How often do you throw them away?


Please answer the following questions so that your prescription can be customized to your lifestyle.

2. How many hours per day are you on an electronic device (computer, phone, e-reader)?

3. Are you bothered by glare/ bright lights?

4. What types of hobbies do you have?

Have you previously had any type of rehabilitation listed below? If so, list the provider.

Vision or Light Therapy

Goals for Neuro-Visual Rehab (What would you like to accomplish?)

What changes would you like to see in yourself?

IF PATIENT IS UNDER 18 YEARS OLD / MINOR:

1) Parent/Guardian

Occupation

2) Number of siblings residing with the patient?

3) Any birthing complications? (cord around neck, oxygen, etc.)

Note #5 form still not done for neuro visul rehab
none 08:00 AM - 06:00 PM 08:00 AM - 06:00 PM 08:00 AM - 05:00 PM 08:00 AM - 05:00 PM CLOSED CLOSED CLOSED optometrist https://g.page/r/CcVEDfi4faIBEAg/review # https://www.facebook.com/russell.eyecare/reviews/?ref=page_internal