Primary EyeCare Associates Minor/Dependent Registration

Date

Name

First Last

Gender

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Email

Communication Preference

Parent/Guardian Name

First Last

Parent/Guardian Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Home Phone

Parent/Guardian Cell Phone

Parent/Guardian Work Phone

Employer

Parent/Guardian Name

First Last

Cell Phone

Employer

Vision Insurance Type

Member Name

First Last

Member Date of Birth

Member Social Security Number

Family Physician and/or Specialist

I understand and agree that (regardless on my insurance status), I am ultimately responsible for the balance of my account for any professional services or materials rendered. I certify this information is true and correct to the best of my knowledge. I will notify the office of any changes in my status of the above information.

Signature

Date

Medical History Information

Please select all of the following that you have or currently experience.

Height

Weight

Tobacco Use:

Please list your current medications and the reason you are taking them.

Please list any drug allergies

Does anyone in your family have the following?

Glaucoma
Macular Degeneration
Diabetes
Lazy Eye
Retinitis Pigmentosa
Other

Are you seeing any specialists for your eyes?

Why are you seeing an eye specialist?

List any past eye surgeries, eye conditions or eye injuries:

Privacy Notice

Notice of Privacy Practices CONSENT FOR TREATMENT While at Primary EyeCare, I consent to all eye evaluations, test and treatments determined to be necessary for me by my doctor. I further consent to my doctor’s use of other authorized individuals to assist in my treatment. FINANCIAL AGREEMENT AND ASSIGNMENT OF INSURANCE BENEFITS I further hereby assume financial responsibility for all charges incurred in consideration of the services rendered, including services that are not covered by Insurance Benefits. I further authorize direct payment to Primary EyeCare for any insurance benefits or Worker’s Compensation Benefits otherwise payable to the undersigned for this treatment at a rate not to exceed Primary EyeCare’s regular charges. It is agreed that payment to Primary Eyecare, pursuant to this authorization, by an insurance company shall discharge said insurance company of any and all obligations under a policy to the extent of such payment. APPLICABLE TO MEDICARE PATIENTS ONLY I certify that the information given by me in applying for payment under the Title XVIII of the Social Security Act is correct. I authorize any owner of medical or other information about me to release to the Social Security Administration or its intermediaries of carriers any information needed for this or any related Medicare claim. I further request that payment of authorized benefits to be made on my behalf. RELEASE OF INFORMATION I further authorize the release of medical information, needed to process any related claims, to my health/vision insurance, my employer to process safety glasses, or service organization. My signature on this form authorizes the above-mentioned releases and acknowledges the receipt of the HIPPA information. Copies of the Privacy Practices are also available upon request at our reception area.

ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I received a copy of PRIMARY EYECARE ASSOCIATES, Notice of Privacy Practices.

Date

Parent/Guardian Name

First Last

Signature

May Primary Eyecare Release your medical/vision information to family?

Name and Phone

May Primary Eyecare leave a message on your home/cell phone regarding your appointment, test results, or upcoming appointments?