Family Vision Center of Porter and Crosby Insurance Authorization Information

ALL FIELDS MUST BE FILLED OUT

Patient Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Social Security Number*
Address
Street Address Address Line 2 City State ZIP / Postal Code
Primary Phone*
Alternate Phone
What is your relationship to the policy holder*
- Self
- Spouse
- Child
- Other
If patient is not policy holder, the next section MUST be completed in order for us to file your insurance
Name of Policy Holder
First Last
Date of Birth
MM slash DD slash YYYY
Social Security Number
Employer
Name of Vision Insurance
Vision Insurance ID#
Phone Number for Customer Service
Name of Medical Insurance
Medical Insurance ID#
Group#
How did you hear about us?
- Mailer
- Insurance
- Internet
- Patient Referral
Patient Referral Name
First Last
Insurance Assignment and Release: I hereby authorize my insurance benefits to be paid directly to the physician and I understand that I am financially responsible for all charges whether or not paid by insurance. I also authorize the physician to release any information required to process all claims.*
Patient or authorized person's signature
Date*
MM slash DD slash YYYY

Patient Information