PAGE 1. IF YOU ARE A NEW PATIENT TO THE OCULAR ONCOLOGY SERVICE, PLEASE PRINT OUT AND FILL IN THIS FORM AND BRING IT WITH YOU TO YOUR FIRST APPOINTMENT.

Wills Eye Hospital
Ocular Oncology Service
840 Walnut Street
Suite 1440
Philadelphia, PA 19107

Dear Patient,

An appointment has been scheduled for you in the office of Shields and Shields and Associates at
Wills Eye Hospital on____________________________at ____________________. This appointment was requested by__________________________________________________.

When you arrive at the Wills Eye Hospital, 900 Walnut Street, Philadelphia, PA, please come directly
to the Oncology Service on the second floor and give your name to the receptionist at the
registration window.

For your appointment it is important that you bring the following:

1. Current, valid insurance card (s) with correct address and telephone number of the insurance company.

2. HMO INSURANCES REQUIRE REFERRAL FORMS. Please contact your primary care physician
to be certain you have the correct number of referral forms with you so that your visit with us
will be without interruption.

PLEASE REMEMBER TO BRING YOUR REFERRAL FORMS WITH YOU AT THE TIME OF YOUR VISIT.
WE CANNOT PROCEED WITH YOUR EXAMINATION WITHOUT PROPER REFERRAL FORMS.

Questions? Please call our office at 215-928-3119. We are happy to assist you.

3. Glasses if they have been prescribed for you.

4. Please complete the enclosed forms and bring them with you to your appointment with us.

By remembering to bring all of the above, you are helping us provide you with the best of care.

For your information our physicians perform a very comprehensive consultation that may include
testing and counseling so we advise each patient to anticipate an all day visit. You may want to
bring a snack with you in the event of any unforeseen delays.

Sincerely,
Oncology Service

PAGE 2. NEW PATIENT INFORMATION

Patients Names: (please print)______________________________________________________
Sex: M__ F__ County you live in:___________________ Marital Status: S__ M__ W__ D__ Sep__
Date of birth:______________________________________SS#___________________________
Patients Address: _______________________________________________________________
______________________________________________________________________________
Occupation: ____________________________________________________________________
Telephone number:_______________________Business telephone:________________________
Patient's or Parent's Employer Name and Address:______________________________________
______________________________________________________________________________
Contact Name:___________________________________________________________________
Address:____________________________________________Phone:______________________
Spouse or Parents Name:________________________________SS#:______________________

PLEASE READ: ALL CHARGES ARE DUE AT THE TIME OF SERVICE. IF HOSPITALIZATION IS
INDICATED, THE PATIENT IS RESPONSIBLE FOR FURNISHING INSURANCE CLAIM FORMS TO
THE OFFICE PRIOR TO HOSPITALIZATION.

Person responsible for payment: (if different from above)_________________________________
Address:______________________________________________Phone: ___________________

Blue Shield: (give name of policyholder)______________________________________________
Effective Date:_____________Certificate/Identification#:______________Group#:______________
Other: (write name and address of insurance company)_________________________________
_______________________________________________________________________________
Effective Date:_________________Group#:__________________Policy#:____________________
Other: (write name and address of insurance company)_________________________________
_______________________________________________________________________________
Effective Date:_________________Group#:______________Policy#:________________________
Medicare: (please give number)_____________________________________________________
Railroad Retirement: (please give number)___________________________________________
Medicaid: (State)_______________Effective Date:______________Program:_________________
County#:_____________________Case#:_________________Account#:____________________

ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT. NECESSARY
FORMS WILL BE COMPLETED TO HELP EXPEDITE INSURANCE CARRIED PAYMENTS, HOWEVER,
THE PATIENT IS RESPONSIBLE FOR ALL FEES REGARDLESS OF INSURANCE COVERAGE. IT IS
ALSO CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAvE BEEN MADE IN ADVANCE WITH OUR BOOKKEEPER.

PAGE 3. INSURANCE AUTHORIZATION AND ASSIGNMENT

NAME OF BENEFICIARY__________________________________HIC#____________________
I request that payment of authorized Medicare benefits be made either to me or on my behalf to
(name of physician/supplier) for any services furnished me by that physician/supplier. I authorize
any holder of medical information about me to release to the Health Care Financing Administration
and its agents any information needed to determine these benefits or the benefits payable to
related services.

I understand my signature requests that payment be made and authorized release of medical information necessary to pay the claim. If item 9 of the HCFA-1500 claim for is completed, my
signature authorizes releasing of the information to the insurer or agency shown. In Medicare
assigned cases, the physician or supplier agrees to accept the charge determination of the
Medicare carrier as the full charge, and the patient is responsible only for the deductible,
coinsurance, and non-covered services. Coinsurance and the deductible are based upon the
charge determination of the Medicare carrier.

Beneficiary Signature________________________________________Date__________________
NAME OF PATIENT: (PLEASE PRINT)__________________________________________________

CONSENT FOR RELEASE OF INFORMATION

I hereby authorize the physician listed below to release information from my medical records:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

The specific information that is to be released is listed below:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Name and address of patient at the time of treatment:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Patients Signature:_____________________________________ Date:______________________
Witness Signature:_____________________________________ Date:______________________

Forward Information To:
Shields and Shields, M.D., P.C.
Wills Eye Hospital, Ocular Oncology Service
840 Walnut Street
Suite 1440
Philadelphia, PA 19107




PAGE 4. MEDICAL INFORMATION

Please provide us with the complete names, addresses and telephone numbers of the following:

PRIMARY OPHTHALMOLOGIST:
Name: (first)______________________________ (last)__________________________________
Specialty:_______________________________________________________________________
Address: _______________________________________________________________________
City:___________________________________ State:_______________ Zip Code:____________
Telephone No. (with area code):_____________________________________________________

REFERRING DOCTOR: (if different from referring doctor)
Name: (first)______________________________ (last)__________________________________
Specialty:_______________________________________________________________________
Address: _______________________________________________________________________
City:___________________________________ State:_______________ Zip Code:____________
Telephone No. (with area code):_____________________________________________________

PEDIATRICIAN (if applicable)
Name: (first)______________________________ (last)__________________________________
Specialty:_______________________________________________________________________
Address: _______________________________________________________________________
City:___________________________________ State:_______________ Zip Code:____________
Telephone No. (with area code):_____________________________________________________

FAMILY MEDICAL DOCTOR
Name: (first)______________________________ (last)__________________________________
Specialty:_______________________________________________________________________
Address: _______________________________________________________________________
City:___________________________________ State:_______________ Zip Code:____________
Telephone No. (with area code):_____________________________________________________

OTHER DOCTOR
Name: (first)______________________________ (last)__________________________________
Specialty:_______________________________________________________________________
Address: _______________________________________________________________________
City:___________________________________ State:_______________ Zip Code:____________
Telephone No. (with area code):_____________________________________________________

OTHER DOCTOR
Name: (first)______________________________ (last)__________________________________
Specialty:_______________________________________________________________________
Address: _______________________________________________________________________
City:___________________________________ State:_______________ Zip Code:____________
Telephone No. (with area code):_____________________________________________________





PAGE 5. PRESENT MEDICATIONS:

1. Name of Medicine_____________________________________________________________
- How often do you take it?__________________________________________________________
- How long have you been using it____________________________________________________

2. Name of Medicine_____________________________________________________________
- How often do you take it?__________________________________________________________
- How long have you been using it____________________________________________________

3. Name of Medicine_____________________________________________________________
- How often do you take it?__________________________________________________________
- How long have you been using it____________________________________________________

4. Name of Medicine_____________________________________________________________
- How often do you take it?__________________________________________________________
- How long have you been using it____________________________________________________

PRIOR EYE CONDITIONS: (please check all appropriate items)
Cataract_________________ Crossed Eyes__________________ Lazy Eye__________________
Glaucoma_________________ Detached Retina_________________ Injury___________________
Other (please specify)_____________________________________________________________

MEDICAL CONDITIONS: (please check all appropriate items)
Heart Condition___________ Prior Heart Attack_________________ Year_________________
Prior Stroke______________ Diabetes_________________ Cancer__________________
Emphysema______________ Ulcer___________________
Blood Disorder____________ Prior Hepatitis____________
Specify type/location______________________________________________________________
Other Condition___________________________________________________________________
Specify type of condition___________________________________________________________
Do you smoke?___________ How much?_____________________________________________
Do you drink alcoholic beverages?________________
Are you allergic to any medicines?____________________If yes, please specify these medicines:
1. _______________________________________ 3.____________________________________
2. _______________________________________ 4.____________________________________

PRIOR SURGERY:
Type of Surgery__________________________________________________________________
_______________________________________________________________________________
Date of Surgery_____________________Surgeon______________________________________
Hospital______________________________________City: _______________________________