Somerton Eyecare Center

Name*

First Middle Last

Birth Date*

Sex

Male
Female

Social Security No.

Mailing Address

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

Phone (Home)

Phone (Cell)

Email

Ocular History

Date of last exam

Name of Doctor

Do you wear glasses?

Yes
No

How often do you wear glasses?

All the time
Occasionally
Reading
Driving

Do you wear contacts?

Yes
No

Which kind of contacts do you wear?

Soft
Hard

Brand of Contacts

Whom may we thank for referring you to this office?

Please list any medication you are taking

Please list any eye drops you use

Please list any medications you are allergic to

Are you pregnant or nursing?

Yes
No

Do you smoke?

Yes
No

Do you have or have you had any of the following? (Check all that apply.)

Insurance Information (Member) for Primary Insurance

Name of Insured

First Last

Insured's Date of Birth

Insured's Social Security #

Policy/ ID #

Insured's Employer

Insured's Employer Phone #

Insurance Company

Insurance Information for Secondary Insurance

Name of Insured

First Last

Insured's Date of Birth

Insured's Social Security #

Policy/ ID #

Insured's Employer

Insured's Employer Phone #

Insurance Company

Insurance Agreement and Release

I, the undersigned, certify that I or my dependent have insurance coverage with the above Insurance Company and assign directly to Somerton Eyecare Center, Inc all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I hereby 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. Please check the method of today's payment below.

Method of Payment

Cash
Check
Debit/Credit
Care Credit

Responsible Party Signature

Financial Policy

In the event that I/we have failed to pay for services provided by this office, and the account is placed for collection, I/we understand and agree that an additional amount equal to 40% of the balance owed at the time the account is placed for collection, we be added to the current balance owed. I/we agree to pay interest at the rate (10%) ten percent per annum until the amount owed is paid in full. I/we further agree to pay all attorneys fee and court cost, necessary to collect this balance. Non sufficient checks will be charged an additional $35 fee.

Patient/Responsible Name

Date

Signature

THANK YOU for trusting us here at Somerton Eyecare Center, Inc. with your vision needs.

Missed Appointment Policy

Our doctor strives to see patients in a timely manner. We respect your time and ask you to respect our time and other patients' need by keeping your appointment. Each appointment time slot is important and cannot be recovered if a patient chooses not to keep their appointment. We collect fees to ensure that our doctor can continue to see patients. Please keep in mind that each skipped or missed appointment is not just time lost, but also time when other patients cannot be seen. Effective 08/01/2012, each missed appointment will be flagged and you will receive a notice that you have missed your appointment. In addition, your account will be assessed a $30 missed appointment fee. Please not that the fee will not be billed to your insurance.

Date

I understand that failure to give 24-hour notice of cancellation of an appointment or not showing up for an appointment can result in a charge of $30. This charge is non-covered by your insurance company and is your responsibly.

Signature

Authorization to Release Records

On April 14, 2003 a new Federal Law HIPAA, went into effect to protect your personal health information (PHI). If you need to authorize someone else to have access to your records in our office please list them and their relationship to you below. Please note, that under this new law we cannot release information to a spouse or a parent if the minor is 18 or older, regardless of who is responsible for the charges.

Name, DOB, and relationship to you

I hereby authorize Somerton Eyecare Center to release my PHI to the listed individuals above until I submit a written request to withdraw them from having such access.

Responsible Party Signature

Date