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Test Patient Forms | Cullom
Phone
Main: (757) 345-3001
LASIK/Cataract Consults: (757) 771-1543

Test Patient Forms
















Patient Agreement

Refraction Charges

A refraction is a diagnostic test used to determine the patient's visual abilities. A series of lenses are presented to determine which prescription provides the sharpest and clearest vision. This test is performed during your annual eye exam or if there has been a recent change in your vision. It is necessary for the physician to perform this test in order to determine the best visual acuity, as well as, evaluate potential eye diseases.


Some insurance companies, including MEDICARE, do not cover the refraction test.


The usual charge for this service is $50.00. If your insurance does not cover this test, Cullom Eye & Laser Center offers a time-of-service discount of 40%. Therefore, if you pay today, your out-of-pocket expense is only $30.00. If you cannot pay today, your charge will be sent through our billing service and your will be billed for the full fee of $50.00.


Initials    Date


Return Appointments:


I understand that I may be given a return appointment in order to follow up on my eye status or condition. In the event that, for any reason, I do not keep that appointment and do not promptly reschedule, I agree not to hold Cullom Eye & Laser Center, it's Physicians, and/or staff responsible for any resulting consequences. Appointments canceled with less than 24 hours notice may be charged to my account.


Initials    Date


Patient Responsibility and Financial Agreement


Specify RMG Facility:


As a patient of this Riverside Medical Group practice, I agree to the following:


1. Medical Treatment Risks: I acknowledge that all medical treatment involves some risks and that no guarantees can be given regarding the outcome.


2. Release Of Prescription History: I authorize any provider who is treating me on behalf of any Riverside facility to request and receive any and all information regarding my medication history including information maintained by the Virginia Prescription Monitoring Program as well as other state and commercial sources.


3. HIV Testing Disclosure: Under Virginia Law, if an RMG employee comes in contact with your blood or body fluids during your care, RMG has the right to do a current HIV and Hepatitis B or C screening. This means that you, the Patient, may be tested for HIV, Hepatitis B or C viruses without your actual consent if this type of exposure occurs during your medical care. The law also requires that the results of these tests be released to the person who is exposed to your body fluids without your consent.


4. Financial Responsibility: I assign any benefits to RMG that I may have for reimbursement for my medical treatment received by RMG which i may be entitled to from any insurance coverage, worker's compensation benefits, disability benefits, and all settlements, judgments and verdicts against any liable third party. If I fail to pay my outstanding RMG balance, I understand RMG will have a lien against any such settlement, judgment, or verdict equal to the full amount of any unpaid RMG bill. I further direct any attorney handling or distribution such proceeds to withhold and promptly pay RMG the full amount of any outstanding balance owed by me, the Patient, to RMG for medical services rendered. I also understand and agree to pay a $30 fee incurred for any returned checks.


4. Financial Responsibility: I assign any benefits to RMG that I may have for reimbursement for my medical treatment received by RMG which i may be entitled to from any insurance coverage, worker's compensation benefits, disability benefits, and all settlements, judgments and verdicts against any liable third party. If I fail to pay my outstanding RMG balance, I understand RMG will have a lien against any such settlement, judgment, or verdict equal to the full amount of any unpaid RMG bill. I further direct any attorney handling or distribution such proceeds to withhold and promptly pay RMG the full amount of any outstanding balance owed by me, the Patient, to RMG for medical services rendered. I also understand and agree to pay a $30 fee incurred for any returned checks.


5. All Payments Due At Time Of Service: While RMG as a courtesy to patients will bill most insurance companies, RMG is under no obligation to do so. If your insurance company fails to pay all or part of your bill, you are responsible for all charges. By signing this agreement, I agree to accept full responsibility of all RMG charges. Full payment is required at the time of service unless other arrangements are made. If any RMG bill is not paid in full at the time of service, RMG reserves the right to charge interest at a rate of 12% from the time of delinquency on any outstanding balance. I agree this Agreement is an original, direct, independent promise to pay based on the independent credit worthiness of the Patient or Responsible Party, and is not a collateral or contingent promise to pay the debt of another. Moreover, I authorize RMG to apply any overpayment from another RMG medical bill to any other accounts owed by the Patient to RMG as a result of any prior treatment or admissions.


6. Pre-Authorization Responsibility: I understand that it is my sole responsibility to obtain all required pre-authorizations for treatment and to fully comply with all pre-authorization requirements as stated by my insurance company. I also understand that if I elect to be treated without a referral from an authorized physician, its my sole responsibility to pay that treating physician.


7. Multiple Bills: I understand that while I am receiving medical treatment at a RMG practice, I may receive a separate bill from a health care provider and/or laboratory other than a bill from the office listed above. For example, I may receive a separate bill from a laboratory, radiologist, pathologist, and other providers. I agree to pay any outside bills received to the extent that it is not paid by my insurance.


8. Disclosure Of Medical Information And Assignment Of Benefits: I authorize RMG to share my medical information and medical records to my insurance company and third party payers. I also assign the benefits payable for the physician services to the physician organization furnishing the services or authorize such physician or organization to submit a claim to Medicare or Medicaid for payment.


9. Patient/Family Conduct: While in any RMG office, I agree to be respectful and courteous to the RMG, all medical providers and other patients. I realize the importance of honoring my scheduled appointments and agree to provide adequate notice for rescheduling appointments. Failure to keep appointments or rescheduling without adequate notice may result in consequences including a charge for the missed appointment. Repeated cancellations may result in discharge from the practice.


10. RMG Is Not Responsible For Loss Of Personal Items: RMG will not be responsible for any loss, theft or damage to any personal property of the Patient (including money, jewelry, documents, clothing, spectacles, dentures, prosthetic devices or other personal articles.


Patient's Name    Date Of Birth    Date & Time

Patient or Responsible Party Signature    Relationship to Patient


Notice of Privacy Practices:

I am aware of and/or have received Riverside's Notice of Privacy Practices brochure. Upon receiving an inquiry as to the presence or condition of the patient, RMG may (unless otherwise requested by the Patient, next of kin, or physician) release at it's discretion: the name, address, age, sex, general nature of injuries, and/or the general condition of the Patient. I understand that a separate written consent is required for me and/or the person(s) listed below to receive copies of my written medical records.

However, I give permission to my physician & office personnel to verbally discuss any and all of my medical conditions(s) with the following person(s).


Name    Phone Number

Name    Phone Number

Name    Phone Number

Name    Phone Number



Medical History


























Patient Medical History 1st Visit 2nd Visit 3rd Visit 4th Visit If Yes, Please give details
Fever/Weight Loss Yes
No
Yes
No
Yes
No
Yes
No
Diabetes/Thyroid Yes
No
Yes
No
Yes
No
Yes
No
Heart Problems Yes
No
Yes
No
Yes
No
Yes
No
Lungs/Breathing Yes
No
Yes
No
Yes
No
Yes
No
Circulation Problems Yes
No
Yes
No
Yes
No
Yes
No
Hepatitis, HIV, AIDS Yes
No
Yes
No
Yes
No
Yes
No
Blood or Lymph Yes
No
Yes
No
Yes
No
Yes
No
Cholesterol Yes
No
Yes
No
Yes
No
Yes
No
Psychiatric Yes
No
Yes
No
Yes
No
Yes
No
Kidney, Bladder Yes
No
Yes
No
Yes
No
Yes
No
Cancer Yes
No
Yes
No
Yes
No
Yes
No
Muscle/Joint Yes
No
Yes
No
Yes
No
Yes
No
Sleep Apnea Yes
No
Yes
No
Yes
No
Yes
No
Pregnant/Nursing Yes
No
Yes
No
Yes
No
Yes
No
Skin Condition Yes
No
Yes
No
Yes
No
Yes
No
Other Yes
No
Yes
No
Yes
No
Yes
No












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Let's "Communicate"

Your Riverside physician and medical care team are strongly committed to using eTechnology to better communicate with you, our patient.


Using eTechnology to Provide Feedback on Our Service


We welcome your comments and suggestions at any time. We also use an independent company, called Press Ganey, to send Riverside Patient Satisfaction Surveys by email to our patients. The report data provided by Press Ganey is confidential. The results of the surveys show us where we can improve our service to better meet your needs. We hope you will take part in these surveys by providing your email address below.


myHealth eLink Connects You with Your Medical Care Team


myHealth eLink is your any-time communication eLink to the physicians of Riverside Medical Group. You can request appointments, prescription renewals, access parts of your personal electronic health record, or send questions to your physician and medical care team. It's your one stop, any-time communication eLink to your physician's office.


To open your communication eLink with your physician's office, provide your email address below. Your medical care team will assist you with your enrollment in myHealth eLink or you may complete your enrollment by visiting www.myhealthelink.com.







Phytel Appointment Reminder System


Riverside Medical Group is now utilizing the Phytel - Appointment Reminder System. Approximately 48 hours prior to your scheduled appointment, our Phytel computer system will generate a call to your home. The system will give a recorded message to the person answering the phone, detailing your appointment date and time.


The person answering the phone will then be given the option to confirm, cancel, or reschedule the appointment. If you choose to cancel or reschedule your appointment a staff member will call you the following day to confirm this option and schedule a new appointment. If there is no answer at your home number, then the recorded message will be left on your answering machine.


Would you like to receive appointment reminder calls from Riverside Medical Group?


  YES, I wish for Riverside Medical Group to utilize the Phytel appointment reminder system to remind me of any future appointments. I Understand that the Phytel system will automatically deliver the message to anyone answering the phone or leave the message on my answering machine.


  I do NOT wish for Riverside Medical Group to utilize the Phytel appointment reminder system to remind me of any future appointments.