The Salem Eyecare Center, Inc

Name*
First Middle Last
Social Security Number
Sex
- Male
- Female
Birth Date*
MM slash DD slash YYYY
Age
Marital Status*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone*
Email*
Primary Care Physician
Date of last visit
MM slash DD slash YYYY
Patient's Employment (if applicable)
Employer
Work Phone
Occupation
Insurance Information
Insurance Company*
Name of Insured*
First Last
Phone
Social Security Number
Member DOB*
MM slash DD slash YYYY
Member Number*
Relationship
Place of Employment
Work Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Vision Insurance
Medical Insurance
Family Members Interested In Becoming Patients
Do you have anyone else in your family interested in becoming a patient?
- Yes
- no
Name
First Last
Relation
Date of birth
MM slash DD slash YYYY
Date of last eye exam
MM slash DD slash YYYY
How Did You Find Out About Our Office*
Co-Payments and fees not covered by your insurance are due upon date of service. A DOWN PAYMENT of 50% is required on materials to start your order. The balance will be due upon pick up of your eyewear. THERE ARE NO CASH REFUNDS ON MATERIALS.
If a prior authorization is required by your insurance, it is the patient's responsibility to contact their primary care provider.
FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS TO SALEM EYECARE CENTER:
I assign to Salem Eyecare Center all medical and vision benefits to which I am entitled. I understand that I am responsible for all charges for professional services rendered. (Except for participating provider agreements between this corporation and your insurance company). I am specifically responsible for certain co-payments and deductibles. I understand that refractive services and other forms of medical care may not be reimbursed by my health care plan and that I will be responsible for these services. A copy of this agreement is also valid. The agreement shall remain in effect until revoked by me in writing. I understand I will be subject to a re-filing fee for supplying false insurance information at date of service.
FULL AUTHORIZATION FOR INFORMATION TRANSFER:
I authorize this office to furnish information (including sensitive medical information) to insurance carriers, healthcare administrators, healthcare providers, and other agencies concerning my medical condition, personal data, and insurance/billing information.
Signature*
Date*
MM slash DD slash YYYY
Entered by*

The Salem Eyecare Center, Inc

Patient's Employment (if applicable)

Insurance Information

Family Members Interested In Becoming Patients

FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS TO SALEM EYECARE CENTER:

FULL AUTHORIZATION FOR INFORMATION TRANSFER: