TEST5557

Name

Title First Middle Initial Last Nickname

Gender

Last 4 of SSN

Date of Birth

Preferred Language

Address

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

Home Phone

Cell Phone

Work Phone

Email

Employer

Primary Care Provider

PCP Phone

PCP Fax

Race

Please mark up to two choices

White
Asian
Black or African American
American Indian or Alaska Native
Native Hawaiian or Other Pacific Islander

Ethnicity

Not Hispanic or Latino
Hispanic or Latino

Insurance Information

Patients must provide insurance card prior to exam

Vision Carrier Name*

Subscriber Name*

Vision Carrier

Relationship to Subscriber*

Vision Carrier

Subscriber Date of Birth*

Vision Carrier

Insurance ID #*

Vision Carrier

Medical Carrier Name*

Subscriber Name*

Medical Carrier

Relationship to Subscriber*

Medical Carrier

Subscriber Date of Birth*

Medical Carrier

Insurance ID #*

Medical Carrier

Is your billing informaion the same as the address above?

Yes
No

Address

Responsible Billing Party

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

Individuals with whom we may share medical information

Name

First Last

Phone

Is this person an Emergency Contact?

Yes
No

Name

First Last

Phone

Is this person an Emergency Contact?

Yes
No

Name

First Last

Phone

Is this person an Emergency Contact?

Yes
No

Financial Agreement / Authorization to Treat

Financial Agreement: I understand that I am responsible for payment of covered and noncovered services (as quoted by the insurance company). In cases where professional goods and services are not covered(denied) by your insurance company, it will be the patient's responsibility to pay for these services. I understand Professional EyeCare Associates may release my information to process all claims for reimbursement on my behalf. Authorization to Treat: I authorize Professional EyeCare associates to furnish optometric care and services, including but not limited to: diagnostic tests, examinations, and other procedures which are deemed necessary in the course of my care.

Patient or Guardian Signature

Date

PRIVACY ACKNOWLEDGMENT

Notice of Privacy Practices: I acknowledge, by my signature below, that I have been given the opportunity to review the Notice of Privacy Practices and I understand that I may request a copy of this notice should I so choose.

Notice of Privacy Practices

Patient or Guardian Signature

Date

Please check the box below if you wish to decline.