Patient Forms KARTESZ EYE CARE INC. PATIENT INFORMATION Offices*Electric Road, RoanokeValley View Blvd., RoanokeTanyard Rd., Rocky MountPlease choose the office for which you are a patientName First Middle Last Date MM slash DD slash YYYY 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 Date of Birth MM slash DD slash YYYY Sex Male Female Social Security Marital Status Employer Work PhoneHome PhoneCell PhoneEmail Address Emergency Contact Phone NoEmergency Contact INSURANCE INFORMATIONPrimary Card Holder Name SS No. Date of Birth MM slash DD slash YYYY Medical Plan Self Spouse Child ID No. Group No. Primary Card Holder Name SS No. Date of Birth MM slash DD slash YYYY Vision Plan Self Spouse Child ID No. Group No. HAS PATIENT BEEN SEEN AT ANY OF OUR THREE LOCATIONS VALLEY VIEW ELECTRIC RD ROCKY MOUNT FINANCIAL POLICIESPLEASE INITIAL AND SIGN THE SIGNATURE LINE BELOWPayment is due on the day of service. All co-pays, non-covered services and materials and co-insurance amounts are due on the day of service. You must present a current insurance card and identification at the time of service.Payment is due on the day of service. All co-pays, non-covered services and materials and co-insurance amounts are due on the day of service. You must present a current insurance card and identification at the time of service. Referrals are to be obtained by the patient from their primary care provider and must be presented before services are provided. 1 will be responsible for charges to my family or me. If my account is sent to collections, all costs associated with collection or legal actions, including a 33 1/3 % attorney fee will be due from me. Materials not picked up within 90 days of notification will be returned to stock or donated. All monies paid will be forfeited.Referrals are to be obtained by the patient from their primary care provider and must be presented before services are provided. 1 will be responsible for charges to my family or me. If my account is sent to collections, all costs associated with collection or legal actions, including a 33 1/3 % attorney fee will be due from me. Materials not picked up within 90 days of notification will be returned to stock or donated. All monies paid will be forfeited. We have a no return policy. All prescriptions glasses and contacts are made to order. We do stand behind our services.We have a no return policy. All prescriptions glasses and contacts are made to order. We do stand behind our services. Our office participates with both medical and vision plans. in the event that your exam is billed medically and there is a remaining balance, we will first exhaust your vision plan benefits before transferring any balance to your account. I authorize the release of any medical or other information necessary to process a claim for services. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the undersigned physician or supplier for services provided today.Our office participates with both medical and vision plans. in the event that your exam is billed medically and there is a remaining balance, we will first exhaust your vision plan benefits before transferring any balance to your account. I authorize the release of any medical or other information necessary to process a claim for services. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to the undersigned physician or supplier for services provided today. HIPAA Acknowledgement Receipt: The offices of Dr. Andrew Kartesz, O.D. and Associates have provided me with a copy of their HIPAA Policy. (HARD COPY AVAILABLE UPON REQUEST)HIPAA Acknowledgement Receipt: The offices of Dr. Andrew Kartesz, O.D. and Associates have provided me with a copy of their HIPAA Policy. (HARD COPY AVAILABLE UPON REQUEST) Dr. Kartesz requires all his patients to have a retinal photo. He feels it is necessary to ensure proper diagnosis that can sometimes go undetected in a routine eye health exam. This test takes a 200 degree image of the back of the eye. In most cases, you will not have to be dilated today. The fee is $20.00. If the doctor finds a medical reason for the photo, we will bill your medical insurance.PATIENT SIGNATUREDate MM slash DD slash YYYY GUARDIAN SIGNATUREDate MM slash DD slash YYYY
Open Saturday's by appointment only