West Branch Eyecare Registration Form

West Branch Eyecare Registration Formadmin2018-10-11T22:14:05+00:00

West Branch Eyecare Registration Form

PERSONAL INFORMATION:
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birthdate*
MM slash DD slash YYYY
Social Security Number
Gender
Marital Status*
Home Phone
Cell Phone*
Other Phone
Email*
SPOUSE or PARENT INFORMATION:
Name of Parent or Spouse*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Other Phone
ADDITIONAL PARENT INFORMATION
Name
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Other Phone
PRIMARY INSURANCE HOLDER
Policy Holder
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Vision Insurance
Medical Insurance
SECONDARY INSURANCE HOLDER:
Policy Holder
Employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Vision Insurance
Medical Insurance
MEDICAL INFORMATION:
Doctor*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Last Exam Date:
MEDICAL HISTORY:
Do You Use Tobacco Products?*
- Current
- Previous
- Never
Advised to quit?
Do You Drink Alcohol?*
- Yes
- No
Other Drugs?*
- Yes
- No
General Allergies
Medication Allergies
List All Medications You Are Taking*
Drug Name Used For Dosage
CURRENT OCULAR STATUS:
Rate Your Vision With Your Current Correction? At Distance:*
- Good
- Fair
- Poor
At arm's length:*
- Good
- Fair
- Poor
At near:*
- Good
- Fair
- Poor
Have you been diagnosed with?
- Cataracts
- Glaucoma
- Macular Degeneration
Are you experiencing any of the following?*
- Eye Strain
- Double Vision
- Eye Pain
- Eye Redness
- Eye Discharge
- Flashes of Light
- Floaters
- None of the Above
Do you have special vision needs for work or hobbies?*
- Yes
- No
Safety glasses:*
- Yes
- No
Sunglasses:*
- Yes
- No
List any eye drops that you are using that weren't mentioned above.*
Drug Name Used For Dosage
I request that payment of authorized insurance benefits be made on behalf of West Branch Eyecare for services furnished to me by the physician. I authorize any holder of medical information about me to release the Health Care Financing Administration and its agents any information needed to determine these benefits or the payment for related services. I understand my signature requests that payment be made and authorize release of medical information necessary to pay the claim. If "other insurance" is indicated in the item 9 of the HCFA-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplieer agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, non covered services, and non assigned claims. Coinsurance and the deductible are based on the charge of the assigned Medicare carrier. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR THE CHARGES NOT COVERED BY MY INSURANCE. THERE WILL BE A $3.00 PROCESSING FEE EACH BILLING AFTER THE FIRST MONTH AND A $20.00 FEE IF SENT TO A COLLECTION AGENCY. West Branch Eyecare is given permission to send/receive reports to/from other doctors, specialists or family members, to call in prescriptions to your pharmacy for you, and to bill your insurance. Please specify any persons you DON'T want information released to:
By signing I also acknowledge that I have been offered a copy of WEST BRANCH EYECARE'S Notice of privacy practices. Signature:
Date
MM slash DD slash YYYY

Drug Name	Used For	Dosage

Drug Name	Used For	Dosage

West Branch Eyecare Registration Form

PERSONAL INFORMATION:

SPOUSE or PARENT INFORMATION:

ADDITIONAL PARENT INFORMATION

PRIMARY INSURANCE HOLDER

SECONDARY INSURANCE HOLDER:

MEDICAL INFORMATION:

MEDICAL HISTORY:

CURRENT OCULAR STATUS: