Pre-Admission - TwoCans.ai

Patient Pre-Admission

Math Captcha: 28 - 22 =

Patient Information

,

Is the Patient diabetic?

No Yes

Is the Patient the Responsible Party?

No Yes

Confirm Patient Information

Responsible Party Information (The individual who is financially responsible for those costs not covered by Insurance)

Responsible Party Information Detail (The individual who is financially responsible for those costs not covered by Insurance)

,

Emergency Contact

,

Procedure Details

ICD-10 Code

(alpha)

CPT Code

-

+

Left

Right

Bilateral

N/A

Total Surgery Time : min

(Must be obtained before surgery can be scheduled)

Auth/Ref Not Required

,

Type of Insurance

Medical / Health / Wellness Auto-related injury Work-related injury Non-covered / Self pay

Patient’s Relationship to Guarantor (Guarantor is the subscriber or policy holder of the insurance policy)

Self Spouse Dependent

Responsible Party

,

Auto Related Injury Information

,

Worker’s Comp Information

,

Primary Insurance

Does [Guarantor] have another policy?

No Yes

Health Insurance Card Front

Health Insurance Card Back

,

Secondary Insurance

Health Insurance Card Front

Health Insurance Card Back

,

Primary Insurance

Secondary Insurance

,

Final Confirmation

Result

,

Please rate your experience

Virginia Eye Institute

Patient Pre-Admission

Patient Information

Confirm Patient Information

Responsible Party Information (The individual who is financially responsible for those costs not covered by Insurance)

Responsible Party Information Detail (The individual who is financially responsible for those costs not covered by Insurance)

Primary Insurance

Secondary Insurance