Randolph Eye Care

Patient Information

Name*

First Middle Initial Last

Date of Birth*

SSN

Marital Status

Single
Married
Divorced
Widowed

Gender

Male
Female

Address

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

Email

Home Phone

Cell Phone

Emergency Contact Name

Emergency Contact Date of Birth

Relationship

Phone Number

Primary Care Physician Name

Pharmacy Name and Address

Employer Information

Name

Work Number

Occupation

Medical Insurance

Primary Carrier

Subscriber ID

Group Number

Policy Holder

First Last

Relationship to Patient

Policy Holder Address

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

(If same, check here)

Same

Policy Holder Date of Birth

Secondary Carrier

Yes
No

Secondary Carrier Insurance

Secondary Carrier Insurance ID

Secondary Carrier Group Number

Policy Holder

First Last

Relationship to Patient

Policy Holder Date of Birth

Vision Insurance (VSP, Spectera, EyeMed)

Name of Plan

Policy Holder Name

First Middle Initial Last

Policy Holder Date of Birth

Policy Holder ID Number or Social Security

Responsible Party (if someone other than patient)

First Last

Date of Birth

Address

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

Phone

Notice of Privacy Practices - Patient Acknowledgment

Patient Name

First Last

Date of Birth

I have received this practice's Notice of Privacy Practices written in plain language. This Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice. I understand I can obtain this practice's current Notice of Privacy Practices on request.

May we leave a message on your answering machine at home or on your cell phone?

Yes
No

May we discuss your medical condition with any member of your family?

Yes
No

If YES, please name the members allowed

Relationship

By signing below, I acknowledge that the information I provided is correct to the best of my ability.

Patient Signature*

Today's Date*

Relationship to patient (if signed by a personal representative of patient)

Guarantor Signature (if other than patient)

Office & Financial Policy

Please read this carefully and if you have any questions please do not hesitate to ask a member of our staff.

We must emphasize that as medical care providers, our relationship is with you, not your insurance company.

1. Please inform our front desk staff if there have been any changes in your insurance coverage. 2. You are responsible for any and all copayments and deductibles as indicated by your insurance company. 3. It is your responsibility to understand your benefit plan and what services are covered. Although the provider may participate with your insurance, it does not necessarily mean all services will be covered. Any services not covered by your plan will be your responsibility. 4. If your insurance requires a referral, it is your responsibility to obtain such prior to your appointment. If a referral is not obtained then you will be responsible for the full cost of your visit. 5. If a valid insurance card is not presented at time of service, then you will be responsible for any and all charges incurred. 6. If a patient's account becomes past due, and sent to collections a $25.00 fee will be assessed. 7. If an appointment is not cancelled at least 24 hours in advance, you will be charged a fifty dollar ($50) fee; this will not be covered by your insurance company.

I have read and understand the financial policy of this practice and I agree to be bound by its terms.

Patient's Name

First Last

Patient's/Guarantor Signature

Date