Patient Registration Kiosk
DO NOT REFRESH THIS PAGE. To navigate between sections, use the Prev/Next buttons on the bottom of the page. Please fill out all required fields.
PAGE 1 of 5
Section 1: BASIC INFORMATION
* - Required Fields
Account Number
Prefix *
Select One
Mr.
Ms.
Dr.
Rabbi
Father
Other
Other Prefix *
First Name *
Middle Initial
Last Name *
Suffix
Date of Birth *
Gender *
Select One
Male
Female
Other
Other Gender *
Marital Status
Select One
Single
Married
Divorced
Separated
Widowed
Domestic Partnership
Street Address *
Unit Number
City *
State *
Select One
Outside of the U.S.
Alabama
Alaska
Arizona
Arkansas
American Samoa
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Trust Territories
Utah
Vermont
Virginia
Virgin Islands
Washington
West Virginia
Wisconsin
Wyoming
Enter State/Province *
Zip Code *
Social Security Number
Driver's License Number
Upload Driver's License/ID
Referral Name
Referral Relationship
Referral Phone Number (if any)
PAGE 2 of 5
Section 2A: CONTACT INFORMATION
* - Required Fields
At least
ONE
Phone Number is required.
Primary Phone *
Home Phone
Work Phone
Work Extension
I don't have an email.
Primary Email *
Other Email
Preferred Method of Communication
Select One
Primary Phone
Home Phone
Work Phone
Primary Email
Other Email
Section 2B: ALTERNATE CONTACT INFORMATION
EMERGENCY CONTACT
No Emergency Contact
Emergency Contact Name
Relationship
Phone Number
Email Address
NEXT OF KIN
Same as Emergency Contact
Next of Kin Name
Relationship
Phone Number
Email Address
Please check if you give permission for our office to communicate directly with the above individual(s).
PAGE 3 of 5
Section 3A: PHYSICIAN INFORMATION
SKIP SECTION IF NO PRIMARY PHYSICIAN
Primary Physician
Phone Number
Section 3B: PHARMACY INFORMATION
SKIP SECTION IF NO PHARMACY
Pharmacy Name
Phone Number
Section 3C: EMPLOYMENT INFORMATION
SKIP SECTION IF NOT EMPLOYED
Occupation
Employer
Phone Number
Section 3D: CREDIT CARD INFORMATION
* - Required Fields
Name on Card
Credit Card Number
Expiration Date
Security Code
Automatically Bill My Card
Please Type In Your Initials To Sign
PAGE 4 of 5
Section 4A: OFFICE INSURANCE POLICES
* - Required Fields
Do you have insurance? *
Select One
I do not have insurance.
I have commercial insurance that is
not
Medicare.
I have Medicare Part B (Government-Issued)
with
Secondary Insurance.
I have Medicare Part B (Government-Issued)
without
Secondary Insurance.
I have Medicare Advantage (Not Government-Issued).
I have Medicaid.
While we do not accept insurance, we will do our best to facilitate the processing of your claims.
Please enter your
Primary
Insurance below.
Primary Insurance Carrier
Policy Number
Group Number
Expiration
Employer
Other Information
**Please bring your Primary Insurance Card with you if you are a New Patient or have a change of insurance.**
Please enter your
Primary
Insurance below.
Primary Insurance Carrier
Policy Number
**Please bring your Primary Insurance Card with you if you are a New Patient or have a change of insurance.**
Please enter your
Primary
Insurance below.
Primary Insurance Carrier
Policy Number
**Please bring your Primary Insurance Card with you if you are a New Patient or have a change of insurance.**
Please enter your
Primary
Insurance below.
Primary Insurance Carrier
Policy Number
**Please bring your Primary Insurance Card with you if you are a New Patient or have a change of insurance.**
Please enter your
Secondary
Insurance below.
While we do not accept insurance, this information will help us to facilitate the processing of your claims.
Secondary Insurance Carrier
Policy Number
Group Number
Expiration
Employer
Other Information
**Please bring your Seconary Insurance Card with you if you are a New Patient or have a change of insurance.**
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- FINANCIAL RESPONISIBILITY POLICY -
Dr. Friedman's office has advised me that they DO NOT participate with my insurance. My decision to have care acknowledges this fact. I understand that his office will do their best to facilitate the processing of my claim, but that I am responsible for all professional services at the time of service. By signing my intials below, I hereby acknowledge that I have read and understood the above policy.
Signature *
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- MEDICARE POLICY -
Release of Information
This is necessary to allow our office to release information to Medicare regarding your care. Please review and sign the acknowledgement. Thank you. I certify that the information given to by me in applying for payment under Title XVIII of the Social Security Act is correct.
(This indicates that the information I have submitted is accurate.)
I authorize any holder of medical or other information about me to release to the Social Security Administrative and Health Care Financing Administrations or its intermediaries or carrier, or to the billing agent of this physician or supplier which is Robert Friedman, M.D., any information needed for this or a related Medicare claim.
(This permits our office to release information to Medicare.)
I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment.
(This allows this form to be used as a proxy for your permission.)
Medicare Part B Confirmation
This is to confirm that you have
government-issued Medicare
(Medicare Part B). We do
not
participate in any other form of Medicare (Medicare Advantage). If you have Medicare Advantage (not government-issued Medicare Part B), you will be personally responsible for any fees.
(This indicates that you have government-issued Medicare Part B and
not
Medicare Advantage.)
By signing my initials below, I herby acknowledge that I have read and understood the above policies.
Signature *
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- MEDICARE POLICY -
Release of Information
This is necessary to allow our office to release information to Medicare regarding your care. Please review and sign the acknowledgement. Thank you. I certify that the information given to by me in applying for payment under Title XVIII of the Social Security Act is correct.
(This indicates that the information I have submitted is accurate.)
I authorize any holder of medical or other information about me to release to the Social Security Administrative and Health Care Financing Administrations or its intermediaries or carrier, or to the billing agent of this physician or supplier which is Robert Friedman, M.D., any information needed for this or a related Medicare claim.
(This permits our office to release information to Medicare.)
I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment.
(This allows this form to be used as a proxy for your permission.)
Medicare Part B Confirmation
This is to confirm that you have
government-issued Medicare
(Medicare Part B). We do
not
participate in any other form of Medicare (Medicare Advantage). If you have Medicare Advantage (not government-issued Medicare Part B), you will be personally responsible for any fees.
(This indicates that you have government-issued Medicare Part B and
not
Medicare Advantage.)
Supplmental Policy
I will personally be responsible to pay the copayment for any services rendered after Medicare processes their payment. By signing my initials below, I herby acknowledge that I have read and understood the above policies.
Signature *
- REFRACTION POLICY -
Medicare does NOT cover refraction, i.e., the prescribing of spectacles. The physician is expected to charge the patient directly for these services.
The fee for this service is $80.00 per encounter.
By signing my initials below, I hereby acknowledge that I have read and understood the above policy.
Signature *
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- MEDICARE ADVANTAGE POLICY -
Robert Friedman, MD, PC participates only with
government-issued Medicare
(Medicare Part B). We do
not
participate in any other form of Medicare (Medicare Advantage). If you have Medicare Advantage (not government-issued Medicare Part B), you will be personally responsible for any fees. By signing my initials below, I acknowledge that I have read and understood the above policy.
Signature *
**The following form(s) are specific to your type of insurance. Please read them and sign your initials below to acknowledge.**
- MEDICAID POLICY -
THIS OFFICE DOES
NOT
ACCEPT MEDICAID. If you have Medicaid, either as primary or secondary insurance, you will be personally financially responsible for any fee for services. The form below indicates your acknowledgement of this responsibility. I acknowledge that I am fully aware of my rights and privileges as a Medicaid enrollee, and that I do understand that I can receive the medical service that I am commissioning from Robert Friedman, M.D. for free or reduced costs by seeking attendance from a participating provider. I request that Dr. Robert Friedman provide me with medical services at the costs stated by his office and recognize that I will be personally responsible for these expenses at the time of services. These charges will NOT be submitted to Medicaid or any authorized agency and are not eligible for reimbursement by any agency. I authorize Dr. Friedman's office to collect the above stated fees by all coventional methods. By signing my intials below, I confirm that my insurance is Medicaid. I acknowledge that you do not accept my Medicaid plan and that I will be responsible for the full fee. I hereby acknowledge that I have read and understood the above policy.
Signature *
- HIPAA FORM -
This is a link to the Government HIPAA Policy. Please click on it to review the policy if you wish.
LINK TO HIPAA
I reviewed the HIPAA Notices of Privacy Practices that is displayed and operative in the office of Robert Friedman, MD, PC. By signing my initials below, I hereby acknowledge that I have reviewed the above policy.
Signature *
PAGE 5 of 5
Section 5: MEDICAL INFORMATION
* - Required Fields
If you have no outstanding history, please select
NONE
.
To indicate any pertinent history, please select
SPECIFY
.
-
PAST MEDICAL HISTORY
-
NONE
SPECIFY
Anxiety Disorder
Arthritis
Asthma
Atrial Fibrillation
Benign Prostatic Hyperplasia
Cerebrovascular Accident
Chronic Obstructive Lung Disease
Coronary Arteriosclerosis
Depressive Disorder
Diabetes Mellitus
Disease Caused by 2019-nCoV
Elevated Blood Pressure
End-Stage Renal Disease
Epilepsy
Gastroesophageal Reflux Disease
History of: Hypertension
Hearing Loss
Human Immunodeficiency Virus (HIV) Infection
Hypercholesterolemia
Hyperthyroidism
Hypothyroidism
Inflammatory Disease of Liver
Leukemia
Malignant Lymphoma
Malignant Tumor of: Breast
Malignant Tumor of: Colon
Malignant Tumor of: Lung
Malignant Tumor of: Prostate
Radiation Therapy Treatment Management
Transplantation of Bone Marrow
Other
-
PAST SURGICAL HISTORY
-
NONE
SPECIFY
Abdominoperineal Resection
Bilateral Replacement of Knee Joints
Biopsy of: Breast
Biopsy of: Prostate
Coronary Artery Bypass Graft
Entire Transplanted Kidney
Excision of: Basal Cell Carcinoma
Excision of: Melanoma
Excision of: Squamous Cell Melanoma
History of: Colostomy
History of: Tubal Ligation
History of: Appendectomy
History of: Bilateral Mastectomy
History of: Cholecystectomy
History of: Colectomy
History of: Liver Excision
History of: Percutaneous Transluminal Coronary Angioplasty
History of: Tissue Graft Heart Valve Replacement
History of: Total Cystectomy
History of: Transurethral Prostatectomy
Hysterectomy
Kidney Biopsy
Low Anterior Resection of Rectum
Lumpectomy of: Both Breasts
Lumpectomy of: Left Breast
Lumpectomy of: Right Breast
Mastectomy of: Left Breast
Mastectomy of: Right Breast
Mechanical Heart Valve Replacement
Oophorectomy
Pancreatectomy
Percutaneous Extraction of Kidney Stone with Fragmentation Procedure
Portosystemic Shunt Operation
Prostatectomy
Prosthetic Arthroplasty of Bilateral Hips
Splenectomy
Surgical Biopsy of Skin
Total Nephrectomy
Total Orchidectomy
Total Replacement of: Left Hip Joint
Total Replacement of: Left Knee Joint
Total Replacement of: Right Hip Joint
Total Replacement of: Right Knee Joint
Transplantation of: Heart
Transplantation of: Liver
Other
-
OCULAR HISTORY
-
NONE
SPECIFY
Allergic Conjunctivitis
Anatomic Narrow Angle Glaucoma - Right Eye
Anatomic Narrow Angle Glaucoma - Left Eye
Blepharitis
Cataract - Right Eye
Cataract - Left Eye
Contact Lenses
Corneal Dystrophy
Macular Degeneration - Right Eye
Macular Degeneration - Left Eye
Dry Eyes
Elevated Eye Pressure - Right Eye
Elevated Eye Pressure - Left Eye
Epiretinal Membrane - Right Eye
Epiretinal Membrane - Left Eye
Glaucoma - Right Eye
Glaucoma - Left Eye
On Exam: Background Diabetic Retinopathy - Right Eye
On Exam: Background Diabetic Retinopathy - Left Eye
Ophthalmic Migraine
Posterior Vitreous Detachment - Right Eye
Posterior Vitreous Detachment - Left Eye
Proliferative Retinopathy Due to Diabetes Mellitus - Right Eye
Proliferative Retinopathy Due to Diabetes Mellitus - Left Eye
Pseudoexfoliation Glaucoma
Retinal Tear without Detachment - Right Eye
Retinal Tear without Detachment - Left Eye
Strabismus
Vitreous Floaters - Right Eye
Vitreous Floaters - Left Eye
Wears Glasses
Other
-
OCULAR SURGICAL HISTORY
-
NONE
SPECIFY
Corneal Transplant - Both Eyes
Corneal Transplant - Right Eye
Corneal Transplant - Left Eye
Descemet's Stripping Endothelial Keratoplasty - Both Eyes
Descemet's Stripping Endothelial Keratoplasty - Right Eye
Descemet's Stripping Endothelial Keratoplasty - Left Eye
History of: Cataract Extraction - Right Eye Structure
History of: Cataract Extraction - Left Eye Structure
History of: Insertion of Drainage Tube into Anterior Chamber - Both Eyes
History of: Insertion of Drainage Tube into Anterior Chamber - Right Eye
History of: Insertion of Drainage Tube into Anterior Chamber - Left Eye
History of: Laser Trabeculoplasty - Both Eyes
History of: Laser Trabeculoplasty - Right Eye
History of: Laser Trabeculoplasty - Left Eye
History of: Photorefractive Keratectomy - Both Eyes
History of: Photorefractive Keratectomy - Right Eye
History of: Photorefractive Keratectomy - Left Eye
History of: Repair of Blepharoptosis - Both Eyes
History of: Repair of Blepharoptosis - Right Eyes
History of: Repair of Blepharoptosis - Left Eyes
History of: Repair of Eyelid - Both Eyes
History of: Repair of Eyelid - Right Eye
History of: Repair of Eyelid - Left Eye
History of: Strabismus Surgery
History of: Trabeculectomy - Both Eyes
History of: Trabeculectomy - Right Eye
History of: Trabeculectomy - Left Eye
Insertion of: Punctal Plug - Both Eyes
Insertion of: Punctal Plug - Right Eye
Insertion of: Punctal Plug - Left Eye
Intravitreal Route - Both Eyes
Intravitreal Route - Right Eye
Intravitreal Route - Left Eye
LASIK - Both Eyes
LASIK - Right Eye
LASIK - Left Eye
Laser Iridotomy - Both Eyes
Laser Iridotomy - Right Eye
Laser Iridotomy - Left Eye
Laser Therapy for Retinal Lesion - Both Eyes
Laser Therapy for Retinal Lesion - Right Eye
Laser Therapy for Retinal Lesion - Left Eye
Strabismus Surgery
YAG Laser Capsulotomy of Lens - Both Eyes
YAG Laser Capsulotomy of Lens - Right Eye
YAG Laser Capsulotomy of Lens - Left Eye
Other
-
FAMILY HISTORY
-
NONE
SPECIFY
History of
GLAUCOMA
NONE
Mother
Father
Sister
Brother
History of
CATARACTS
NONE
Mother
Father
Sister
Brother
History of
MACULAR DEGENERATION
NONE
Mother
Father
Sister
Brother
History of
OCULAR MELANOMA
NONE
Mother
Father
Sister
Brother
-
SOCIAL HISTORY
- *
NONE
SPECIFY
Cigarette Smoking
NEVER
Former Smoker
Current - Some Days
Current - Everyday
Alcohol Use
NONE
Less than 1 drink per day
1-2 drinks per day
3 or more drinks per day
-
ALLERGIES
- *
NONE
SPECIFY
-
MEDICATIONS
- *
NONE
SPECIFY
-
REVIEW OF SYSTEMS
-
NONE
SPECIFY
Allergy to Adhesive
Allergy to Latex
Allergy to Dilation Drops
Allergy to Fluorescein
Taking Blood Thinners
Taking Flomax
Fever
Chills
Weight Loss
Stuffy Nose
Dry Mouth
Rapid Heart Rate
High Blood Pressure
Cough
Congestion
Shortness of Breath
Upset Stomach
Diarrhea
Constipation
Burning on Urination
Urinary Frequency
Joint Pains
Stiffness
Arthritis
Rash
Changing Moles
Headache
Seizure
Stroke
Anxiety
Depression
Diabetes
Thyroid Abnormalities
Allergies
Hay Fever
Hives
Bleeding
Anemia
MRSA
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