Family Optometric Vision Care

Welcome to Family Optometric Vision Care!

NAME:

First Last

DATE:

GENDER:

DOB:

AGE:

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ADDRESS:

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OCCUPATION:

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CONTACT INFORMATION:

Home Phone:

Cell Phone:

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*If under the age of 18 parent or guardian information:

Phone#:

Name:

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Relation:

VISION INSURANCE:

Name of Ins:

Policy Holder's Name:

First Last

Policy Holder's SSN:

Policy Holder's DOB:

Name of 2nd Ins:

Policy Holder's Name:

First Last

Policy Holder's SSN:

Policy Holder's DOB:

MEDICAL INSURANCE:

Name of Ins:

Policy Holder's Name:

First Last

Policy Holder's SSN:

Policy Holder's DOB:

Acknowledgement of Receipt of Notice of Privacy Practices

In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct healthcare operations involving our office. By signing this form below, you acknowledge having received the Notice of Privacy Practices from Family Optometric Vision Care.

Financial Responsibility Waiver

Insurance Authorization, Verification, and Co-Payments are the responsibility of the member. I understand that if my insurance benefits and/or eligibility are not approved by my health plan, then I am financially responsible and agree to pay for all charges related to services provided by Family Optometric Vision Care. This waiver will remain valid from this day forward to include all future services related to this patient.

Signature (or Guardian)

Date