Seal Beach Eyes

Patient Info
Name
Prefix First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Home)
Phone (Work)
Phone (Other/Cell)
Social Security Number
Date of Birth
MM slash DD slash YYYY
Age
Sex
Marital Status
Spouse's Name
First Last
Employment
Occupation
Company
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Email

Insurance
Vision Plan
ID#
Subscriber
Date of Birth
MM slash DD slash YYYY
Relationship to Subscriber
Medical Plan
ID#
Subscriber
Date of Birth
MM slash DD slash YYYY
Relationship to Subscriber
ASSIGNMENT AND RELEASE PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I hereby authorize this vision care provider to apply for benefits on my behalf for covered services rendered and request that all payments be made directly to the vision care provider. I agree to assume all responsibility of full charges whether or not paid by insurance. I further authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Responsible Party Signature
Date
MM slash DD slash YYYY
Health Insurance Portability and Accessibility Act – ACKNOWLEDGE OF NOTICE OF PRIVACY PRACTICE It is often necessary to use and disclose health information that identifies you in order to treat you, to obtain payment for our services, and, to conduct healthcare operations involving our office. The Notice of Privacy Practices describes these uses and disclosures in detail. Our office is in full compliant with HIPAA, and a copy of the Notice of Privacy Practice is available if you'd like a copy for your records.
Signature
Date
MM slash DD slash YYYY
How did you hear about our office?
- Insurance List
- Local Internet Search
- Referral
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Patient Info