Eye Clinic, LLC – Versailles – Patient Registration Forms

The Eye Clinic, LLC
Dr. Kevin K.E. Carl - Dr. Desmon Carl
Name
First Middle Last
Age
Gender
- Male
- Female
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell/Home
Email
SS #
Date of Birth
Month
Day
Year
Occupation
Business Phone
Employed By
If student, name of school
Parent/Guardian
First Last
Insurance
Policy Number
Policy Holders Name
First Last
Date of Birth
Month
Day
Year
Spouses Name
First Last
SS #
Employed By
Business Phone
Child/Children Names
Ages
Emergency Contact
First Last
Phone #
Whom may we thank for referring you?
Assignment and Release
I hereby authorize payment directly to Dr. Kevin Carl and/or Dr. Desmon Carl of all insurance benefits otherwise payable to me for the services rendered. I understand that I am financially responsible for alt charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize Dr. Kevin Carl and/or Dr. Desmon Carl to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Signature of Responsible Party
Date
MM slash DD slash YYYY
ONE TIME AUTHORIZATION
Name of Beneficiary:
First Last
HI Claim Number
I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Kevin Car1amor Dr. Desmon ar for any services fiimished me by that physician. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agent any information needed to determine these benefits or the benefits payable for related services.
Patient’s Signature
Date Signed
MM slash DD slash YYYY
ACKNOWLEDGEMENT OF RECEIPT
Our Privacy Practice policy is available for anyone who would like a copy, just inform the front desk if you would like a copy. Please sign below even if you choose not to receive a copy of our Privacy Practice policy. I acknowledge that I received a copy of Dr. Kevin Carl and/or Dr. Desmon Carl’s notice of Privacy Practices.
Date
MM slash DD slash YYYY
Patients Name
First Last
Signature

Eye Clinic, LLC - Versailles

Step 1 of 3

The Eye Clinic, LLC

Assignment and Release

ONE TIME AUTHORIZATION

ACKNOWLEDGEMENT OF RECEIPT

Please fill out the following to the best of your knowledge.

Medical History

Family History

Social History

Review of Systems