(703) 766-6165Fax: (703) 345-9356
Crenshaw&Belani, MD
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Patient Resources

New Patient Registration

Fill out the four-page form below, then click Print Form to print it and bring it with you to your scheduled visit. You can also save it as a PDF from your browser's print dialog.

New patients must arrive at the clinic 15 minutes before their scheduled appointment. Please also call your previous eye doctor and ask them to fax your records to (703) 345-9356 before your visit.

All Forms

Joanne Crenshaw, M.D

Shaleen Belani, M.D.

Tarek Khalil, O.D.

NEW PATIENT REGISTRATION

Date:
Last NameFirst NameM.I.Sex:
Social Security #(Confidential; for billing purposes only)DOBMarital status:

Street Address:City:State:Zip:

Home Phone#:Work Phone#:Cell phone#:

Employer:Occupation:May we call your place of employment? Y N

Email:(Your email gives you access to the patient portal to access/update your medical records.)

LOCALPharmacy Name:City:Phone:

Primary Care Doctor's Full Name//Phone:

Referring Provider's Name/Address/Phone (if different than PCP):

Language: English: Other:

Race:White Black/African American American Indian/Alaska Native

Asian Native Hawaiian/Other Pacific Islander Decline response

PRIMARY INSURANCE INFORMATION

Insurance Co. Name:ID #:Group #:

Policy holder's Name:Relationship to Patient:

Policy holder's Social Security #DOB

Street Address:City:State:Zip:

Home Phone#:Work Phone#:Cell Phone#:

SECONDARY INSURANCE INFORMATION

Insurance Co. Name:ID #:Group #:

Policy holder's Name:Relationship to Patient:

Policy holder's Social Security #DOB

Street Address:City:State:Zip:

Home Phone#:Work Phone#:Cell Phone#:

Person(s) you would like to authorize to receive/discuss medical information:

Person to contact in case of an emergency:Phone#:

Relationship

I hereby authorize Joanne Crenshaw, MD, PC to apply for benefits on my behalf for services rendered and authorize the release of any information acquired in the course of my treatment necessary to process insurance claims. I request payment from the above indicated insurance carrier to be made directly to Joanne Crenshaw, MD, PC, realizing that I am responsible for all non-covered charges. I also realize I am responsible for any other costs incurred while collecting my outstanding balance(s). I acknowledge their notice of privacy practices is available to me upon request. I certify that the information I have reported is correct to the best of my knowledge. This is to remain in effect indefinitely unless revoked in writing by the undersigned.

Patient, Parent or Guardian Signature: Date:

Our Financial Policy

We are committed to providing you with the highest level of service and quality care. If you have medical insurance, we will strive to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our financial policy.

I understand that Joanne Crenshaw M.D., P.C. does not participate with any vision plans.

It is my responsibility to contact and secure from my insurance plan any referrals, pre-certifications or authorizations prior to receiving medical services. If a referral is required and I do not bring it with me, I will be asked to pay for the visit prior to the exam.

All co-pays, coinsurance and deductible charges as well as past due balances, will need to be paid prior to services rendered. If I have financial difficulty and cannot pay a past due balance, I agree to make payment arrangements by credit card, which will be kept on file and charged at intervals agreed upon by the billing department and myself.

Joanne Crenshaw M.D. PC will file for insurance benefits and accept payments per contractual agreements with participating insurance companies. Knowing the terms, limitations and guidelines of my health insurance policy is my responsibility as a patient and I assume all financial responsibility for any charges incurred as a result of policy termination or coordination of benefits or limitation otherwise not mentioned that results in nonpayment.

Should any balances arise due to insurance copayments, coinsurance, deductibles, insurance denials, termination of coverage, or any other reason, I agree to pay all charges within 60 days of service rendered. Interest of one and a half percent (1.5%) per month, 18% per annum may be charged on all delinquent accounts over 60 days. I agree to pay an additional fee of 30% if this account is sent to collections. (PLEASE INITIAL)

There will be a $25.00 charge for medical records or any forms which need to be filled out by the physician.

There will be a $75.00 fee for missed appointments not canceled or changed 48 business hours prior to the scheduled appointment and a $250.00 fee for any procedures not canceled three days prior to the scheduled procedure. Legitimate emergencies will be taken into consideration.

If for any reason a check is returned on my account, I will be responsible for a $35.00 returned check fee in addition to the original fees for services.

IMPORTANT PAYMENT INFORMATION ABOUT REFRACTIONS: A refraction is the process of determining the eye's refractive error. It is an essential part of an eye examination and necessary to write a prescription for glasses or contact lenses. However, it is considered a non-covered service by insurance companies; thus, it becomes the responsibility of the patient to pay for the refraction portion of the exam. Our fee for the refraction is $65.00 and is collected at the time of your visit, in addition to any co-payments or deductible due for the medical portion of your exam. If your insurance company pays for the refraction, you will be refunded.

OR

I have read and understand the above financial policy.

Signature of patient/guardian/parentPrinted name of patientDate

Joanne Crenshaw, M.D., P.C.

21135 Whitfield Place, #102

Sterling, VA 20165

(703) 766-6165

NOTICE OF PRIVACY PRACTICES

I, , hereby authorize Joanne Crenshaw, M.D., P.C. to use and or disclose my health information which specifically identifies me or which can reasonably be used to identify me to carry out my treatment, payment and healthcare operations. I understand that while this consent is voluntary, if I refuse to sign this consent, Dr. Crenshaw can refuse to treat me.

I have been informed that Dr. Crenshaw has prepared a notice ("Notice") that more fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. I understand that I have the right to review such ("Notice") prior to signing this consent.

I understand that I may revoke this consent at any time by notifying Dr. Crenshaw in writing, but if I revoke my consent, such revocation will not affect any actions that Dr. Crenshaw took before receiving my revocation.

I understand that Dr. Crenshaw has reserved the right to change his/her privacy practices and that I can obtain such changed notice upon request.

I understand that I have the right to request that Dr. Crenshaw restricts how my individually identifiable health information is used and or disclosed to carry out treatment, payment or health care operations. I understand that Dr. Crenshaw does not have to agree to such restrictions, but that once such restrictions are agreed to, Dr. Crenshaw must adhere to such restrictions.

Signature of patient or patient's representative    Date:

Printed name of patient or patient's representative

Relationship to patient

OR

I refuse to sign this consent form, which acknowledges Dr. Crenshaw's implementation of HIPAA privacy regulations.

Signature of patient or patient's representative    Date:

Printed name of patient or patient's representative

Relationship to patient

Medical History Form

Name:Date:

Current eye problem:

REVIEW OF CURRENT HEALTH:YESNODETAILS
GENERAL (fever, weight loss, malaise…)
EAR/NOSE/THROAT (stuffy nose, ear ache, cough, dry mouth…)
CARDIOVASCULAR (chest pain, racing pulse…)
RESPIRATORY (congestion, wheezing…)
GASTROINTESTINAL (stomach upset, diarrhea, constipation)
GENITOURINARY (urinary flow problems)
MUSCLES, BONES, JOINTS (joint pain, stiffness, swelling)
SKIN (rashes, suspicious growths)
NEUROLOGICAL (headache, numbness, paresthesias)
PSYCHIATRIC (depression, anxiety)
ENDOCRINE (hot/cold intolerance)
HEMATOLOGIC (bleeding disorder, anemia)
ALLERGIC/IMMUNOLOGIC (sneezing, swollen nodes, hives)

***Please provide the following information if NOT registered on line through our portal:

Medications you currently take with strength and dosage:

Allergies to medications:

; IF YES, please list:

List all major illnesses:

List any surgeries you have had:

Family History

Family HistoryMotherFatherSisterBrotherMaternal GMMaternal GFPaternal GMPaternal GF
Glaucoma
Macular Degeneration
Retinal Detachment
Diabetes
Hypertension
Stroke
Thyroid Disease
Cancer
Other

Social History

Smoking: ( packs per day) ( pack years)

Alcohol: ; If yes, how much per week?

Drug use:

Your information is not submitted online — printing keeps it with you to hand-deliver at your visit.