Eye Center of Connersville

Patient Information
Name*
First Last
Gender*
- M
- F
Date of Birth*
MM slash DD slash YYYY
Age*
Marital Status*
- Single
- Married
- Divorced
- Widowed
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SSN*
Referral
Home Phone*
Family Physician
Contact Info
Contact Home Phone
Contact Cell Phone
If the patient is a minor, the following must be complete:
Responsible Party
Address (if different from patient's)
Patient Relationship to Responsible Party
Insurance ID #
Date of Birth for Responsible Party
MM slash DD slash YYYY
All patients and/or responsible parties, please complete the following:
Employer*
Email*
Primary Insurance*
Subscriber's Date of Birth*
MM slash DD slash YYYY
Subscriber's ID #*
Relationship to Patient*
Date*
I hereby authorize my Insurance carrier(s) to submit payment for services provided to me directly to Whitewater Eye Centers and/or Whitewater Surgery Center. I authorize any holder of medical information about me to release to my insurance carriers any information needed to determine benefits payable for related services. I request payment of authorized Medigap benefits as applicable to be released to Whitewater Eye Centers and/or Whitewater Surgery Centers. I understand that I am responsible for payment of services and failure to pay amounts owed by me may be subject to collection fees of up to 50% of the delinquent amount and/or attorney and court fees as applicable.

I hereby acknowledge receipt of the Whitewater Eye and Surgery Center Patient Privacy notice issued on the date below.

MM slash DD slash YYYY
Signature*

Eye Center of Connersville

Patient Information

If the patient is a minor, the following must be complete:

All patients and/or responsible parties, please complete the following: