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Baird Optical Co Inc Patient Registration Form
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2018-03-02T18:39:07+00:00
Baird Optical Co Inc Patient Registration Form
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Patient Registration Form
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Female
DOB
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S.S.
Address
Cell Phone
E-mail
Occupation
Emergency Contact Name
Emergency Contact Number
Primary Care Doctor
Primary Care Doctor Phone
Primary Care Doctor City/State
How Did You Hear About Us?
Guarantor: If patient is a minor
Name
Relation
DOB
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S.S.
Address
Phone
Approval for dilation/treatment:
Yes
No
Guarantor/Guardian Signature:
Insurance Information
Primary Company
Policy/ID#
Group#
Policy Holder's Name
DOB
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S.S.
Employer Name
Phone
Secondary Company
Policy/ID#
Group#
Vision Insurance
Policy/ID#
Policyholder
Signature
Medicare Signature on File: I request that payment of authorized Medicare payments be made on my behalf to Baird Optical Co, Inc. for services furnished to me. Furthermore, I have authorized to release to my insurance carrier(s) any and all information needed to determine the benefits payable to related services. Although the providers of Baird Optical Co, Inc. may or may not participate with my insurance carrier(s), I understand that I am financially responsible for co-payments, deductibles and unpaid balances.
Date
MM slash DD slash YYYY
Contact Method
I hereby give Baird Optical Co, Inc. my permission to contact me at all of the contact numbers and addresses provided in order to communicate my protected health information (or that of my child) including results, prescriptions, and appointment information. This communication may be via US mail, phone, answering machine, mobile phone or email. Please list restrictions here:
Signature
Date
MM slash DD slash YYYY
Baird Optical Co, Inc. Patient Registration Con’t
Private Insurance Authorization for Assignment of Benefits and Release of Information
I hereby authorize the direct payment of my medical benefits to Baird Optical Co, Inc. for any services furnished to me. I authorize the doctor to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. In the event that my health plan determines a service to be “not covered,” I will be responsible for the complete charge. I agree to be responsible for all unpaid services rendered on my behalf or my dependents, including any fees for collection services needed. If my insurance company does not pay the practice within 30 days, I will be responsible for the bill. Payment is due upon receipt of a statement from our office.
Signature
Date
MM slash DD slash YYYY
In order to stay in compliance with the federal government, we must record the following information:
Race
White
Black/African American
Asian
Other
Ethnicity
Hispanic
Other
Primary Language
English
Spanish
Indian
Russian
Other
HIPPA Registration
Patient
DOB
Month
1
2
3
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9
10
11
12
Day
1
2
3
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5
6
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9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
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1932
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Relation
Patient/Guardian Signature
I acknowledge understanding and/or the receipt of the Notice of Privacy Practices for Baird Optical Co, Inc.
Date
MM slash DD slash YYYY
Optional Delegation of Patient Representation
By signing below, I hereby authorize the disclosure of my Protected Health Information (PHI), or that of my child, as well as appointments, and billing information to be shared with the person(s) listed below.
Name
Relation
Phone
Name
Relation
Phone
Signature
Date
MM slash DD slash YYYY
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