Baird Optical Co Inc Patient Registration Form

Patient Registration Form
Name
- Male
- Female
DOB
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
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
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
Date Format: 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
Date Format: MM slash DD slash YYYY

Baird Optical Co Inc Patient Registration Form

Step 1 of 2

Patient Registration Form

Guarantor: If patient is a minor

Insurance Information

Contact Method

Baird Optical Co, Inc. Patient Registration Con’t

Private Insurance Authorization for Assignment of Benefits and Release of Information

In order to stay in compliance with the federal government, we must record the following information:

HIPPA Registration

Optional Delegation of Patient Representation