[5557] – Professional EyeCare Associates – Patient Registration Forms

Gender

Last 4 of SSN

Date of Birth

Preferred Language

Home Phone

Cell Phone

Work Phone

Email

Employer

Primary Care Provider

PCP Phone

PCP Fax

Insurance Information

Patients must provide insurance card prior to exam

Vision Carrier Name

Subscriber Name

Vision Carrier

Relationship to Subscriber

Vision Carrier

Subscriber Date of Birth

Vision Carrier

Insurance ID #

Vision Carrier

Medical Carrier Name

Subscriber Name

Medical Carrier

Relationship to Subscriber

Medical Carrier

Subscriber Date of Birth

Medical Carrier

Insurance ID #

Medical Carrier

Individuals with whom we may share medical information

Phone

Notice of Privacy Practices: I acknowledge, by my signature below, that I have been given the opportunity to review the Notice of Privacy Practices and I understand that I may request a copy of this notice should I so choose. Financial Agreement: I understand that I am responsible for payment of covered and noncovered services (as quoted by the insurance company). In cases where professional goods and services are not covered(denied) by your insurance company, it will be the patient's responsibility to pay for these services. I understand Professional EyeCare Associates may release my information to process all claims for reimbursement on my behalf. Authorization to Treat: I authorize Professional EyeCare associates to furnish optometric care and services, including but not limited to: diagnostic tests, examinations, and other procedures which are deemed necessary in the course of my care.

Patient or Guardian Signature

Date

[5557] Professional EyeCare Associates - New Patient Form

Insurance Information

Individuals with whom we may share medical information

Please complete this form as accurately and completely as possible.

Please indicate if you (the patient) or a family member ever had the following conditions: