MOUNTAINEER VISION CENTER, PLLC

DR. MARK D. ROBINSON DR MICHAEL R. LOOPER

827 Fairmont Road, Suites 105-106 - Morgantown, WV 26501
Phone: (304) 296 3333; Fax: (304) 296 2220
http://www.mvcpllc.com
MEDICAL HISTORY
PATIENTS NAME: _________________________________________________

DATE: _______________________

- PART ONE -

DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS?

CONDITION

YES

NO

MEDICATIONS

HOW LONG

HYPERTENSION
HEART DISEASE
STROKE
DIABETES
THYROID DISEASE
ARTHRITIS
SINUSITIS
EMPHYSEMA
ASTHMA
KIDNEY DISEASE
HEADACHE
HEAD INJURY
LIVER DISEASE
SEIZURES/TREMORS
LUPUS
ROSACEA
HIGH CHOLESTEROL
CANCER

- PART TWO -

DO YOU HAVE ANY OF THE FOLLOWING EYE CONDITIONS?

CONDITION

YES

NO

MEDICATIONS

HOW LONG

GLAUCOMA
MACULAR DEGENERATION
CATARACTS
RETINAL DETACHMENT
EYE INJURIES
EYE SURGERIES
BLINDESS
LAZY EYE

DO YOU HAVE DRY EYES?

YES

NO

DO YOU HAVE AIRBORNE ALLERGIES? YES

NO

LIST ALL ALLERGY MEDICATIONS BELOW:

________________________________________________________________________________________
ARE YOU ALLERGIC TO ANY MEDICINES?

YES

NO

IF YES, PLEASE LIST BELOW:

________________________________________________________________________________________

Page 1 of 5

Reviewed By: _________ Date: ________

- PART THREE -

DO ANY OF YOUR FAMILY MEMBERS HAVE ANY OF THESE MEDICAL CONDITIONS?

CONDITION

YES

NO

WHICH FAMILY MEMBERS

HYPERTENSION
HEART DISEASE
STROKE
DIABETES
GLAUCOMA
CATARACT
RETINAL DETACHMENT
EYE SURGERIES
BLINDNESS
MACULAR DEGENERATION

- PART FOUR -

GENERAL QUESTIONS TO ASSIST US IN MEETING YOUR NEEDS AND CONCERNS.

PLEASE LIST THE REASON(S) FOR YOUR VISIT TODAY:

_________________________________________________________________________________________

DO YOU WANT (CIRCLE ONE)

ARE YOU PREGNANT?

(PLEASE CIRCLE)

YES

NO

DO YOU SMOKE?

(PLEASE CIRCLE)

YES

NO

DO YOU USE BIRTH CONTROL?

(PLEASE CIRCLE)

YES

NO

GLASSES

CONTACT LENSES

BOTH

- PART FIVE PATIENT INFORMATION PLEASE FILL OUT FULLY & COMPLETELY. THANK YOU.
PATIENTS INFORMATION
FIRST NAME: _____________________________ MI: _____ LAST NAME: ____________________________
ADDRESS: __________________________________________________________________ APT #: ________
CITY: ________________________________________

STATE: ________ ZIP CODE: _______________

HOME PHONE: _________________ WORK PHONE: ________________ CELLPHONE: _________________

E-MAIL ADDRESS: ___________________________________________________________________________
OCCUPATION: ______________________________ DATE OF BIRTH: __________________ AGE: _________
MARITAL STATUS: SINGLE MARRIED LEGALLY SEPARTED DIVORCED WIDOWED
EMPLOYER/SCHOOL: _____________________________________________ GENDER:

MALE

FEMALE

SOCIAL SECURITY NUMBER: ____________________________________________________

FAMILY DR.: __________________________________ FAMILY DR. PHONE #: _______________________

Page 2 of 5

Reviewed By: _________ Date: ________

GUARANTOR INFORMATION (IF NOT SELF OR PATIENT IS A MINOR)

FIRST NAME: ____________________ MI: ______LAST NAME: __________________________
ADDRESS (IF DIFFERENT THEN PATIENT)____________________________________________
CITY: _______________________________STATE; _______________ZIP CODE: ____________
HOME PHONE: ________________ WORK PHONE: _____________CELL: __________________
EMPLOYER: _____________________________________________________________________

INSURANCE CARRIER INFORMATION

PRIMARY VISION INSURANCE: ________________________________

ID #: _____________________

INSUREDS NAME: _____________________________________DATE OF BIRTH:___________________

ADDRESS IF DIFFERENT THEN PATIENT: ____________________________________________________
CITY: _________________________________STATE: _________ ZIP CODE: _______________________
RELATIONSHIP TO PATIENT: ___________________________________
SECONDARY VISION INSURANCE: ______________________________

MALE OR FEMALE
ID #:_____________________

INSUREDS NAME: __________________________________________DATE OF BIRTH:_______________

RELATIONSHIP TO PATIENT: ___________________________________

MALE OR FEMALE

PRIMARY MEDICAL INSURANCE:

ID #: _____________________

______________________________

INSUREDS NAME: __________________________________________DATE OF BIRTH:_______________

ADDRESS (IF DIFFERENT THEN PATIENT)____________________________________________________
CITY: _________________________________STATE: _________ ZIP CODE: _______________________
RELATIONSHIP TO PATIENT: __________________________________

MALE OR FEMALE

SECONDARY MEDICAL INSURANCE: __________________________ID# __________________________

INSUREDS NAME: __________________________________________DATE OF BIRTH: ______________
RELATIONSHIP TO PATIENT: _________________________________

Page 3 of 5

MALE OR FEMALE

Reviewed By: _________ Date: ________

REFERRAL INFORMATION
HOW DID YOU HEAR ABOUT US?
YELLOW PAGES
DAILY ATHENAEUM

(CIRCLE ONE)

NEWSPAPER AD

FRIEND/CO-WORKER / NAME: _____________________

MVC, PLLC WEBSITE WALKED IN TO CENTER

DO YOU HAVE A COUPON?

YES

NO

OTHER: ________________

(IF YES, PLEASE PRESENT TO RECEPTIONIST.)

-- PART SIX

PATIENT FINANCIAL RESPONSIBILITY PLEASE READ CAREFULLY AND SIGN BELOW. THANK YOU.
I, HEREBY AUTHORIZE MOUNTAINEER VISION CENTER, PLLC TO APPLY FOR BENEFITS ON MY
BEHALF FOR COVERED SERVICES RENDERED BY THEM. I ALSO ASSIGN MY BENEFITS AND REQUEST
THAT ALL PAYMENTS FROM MY INSURANCE COMPANY BE MADE DIRECTLY TO MOUNTAINEER
VISION CENTER, PLLC. I AGREE TO PAY ALL CHARGES SHOWN BY STATEMENTS, PROMPTLY UPON
THEIR PRESENTATION, UNLESS CREDIT ARRANGEMENTS ARE AGREED UPON IN WRITING.
I CERTIFY THAT THE INFORMATION I HAVE REPORTED WITH REGARD TO MY COVERAGE IS
CORRECT. I HEREBY AUTHORIZE THE RELEASE OF ANY MEDICAL INFORMATION NECESSARY IN
ORDER TO PROCESS A CLAIM FOR PAYMENT IN MY BEHALF.
________________________________________________________________________________________
PATIENT/GUARDIAN SIGNATURE
DATE
________________________________________________________________________________________
PATIENT/GUARDIAN PRINTED
DATE

Page 4 of 5

Reviewed By: _________ Date: ________

Mountaineer Vision Center, PLLC

Dr. Mark D. Robinson, O.D.
Dr. Michael R. Looper, O.D.
827 Fairmont Road
Suite 105-106
Morgantown, WV 26501

Acknowledgment of Receipt of Privacy Notice:

I have been presented with a copy of this practice's Notice of Privacy Policies, detailing
how my information may be used and disclosed as permitted under federal and state law.
I understand the contents of the Notice, and I request the following restrictions(s)
concerning the use of my personal medical information:
I

Further, I permit a copy of this authorization to be used in place ofthe original.

Date:

Signed:

lfnot signed by the patient, please indicate relationship to patient (e.g., spouse).
Relationship:
Witnessed by:
If the patient refuses to sign. indicate your attempt to obtain a signature below.
( ) Patient refused to sign this acknowledgement.
Date: -----

Page 5 of5

Time: -----

Employee name: