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

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