Witt Eye Centers Patient Registration Form

Witt Eye Centers Patient Registration

Patient Information
Name
First Last
Preferred Name (if applicable)
Date of Birth
MM slash DD slash YYYY
Age
Sex
Social Security #
Work Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Marital Status
Employer Name
Emergency Contact Name
Relationship to Patient
Emergency Contact Phone
Responsible Party - patients under the age of 18 cannot be guarantor
Relationship to Patient
Guarantor Name
Date of Birth
MM slash DD slash YYYY
Social Security #
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Primary Insurance
Ins. Co. Name
Policy Number
Patient Relationship to Policy Holder
Policy Holder Name
Policy Holder's Date of Birth
MM slash DD slash YYYY
Secondary Insurance
Ins. Co. Name
Policy Number
Patient Relationship to Policy Holder
Policy Holder Name
Policy Holder's Date of Birth
MM slash DD slash YYYY
Signature*
I certify that I have read and agree to the Witt Eye Ceters (WEC) payment policy. I authorize WEC to bill my insurance company for services provided and agree to be responsible for any charges not covered. I authorize WEC to release any medical information to my insurance carrier or third party payer processing my insurance claims. I understand failure to pay outside balances within 90 days of notification of the amount due will result in submission to an outside collection agency. I understand that if I default on my account. WEC may not allow me to schedule future appointments.
Today's Date
MM slash DD slash YYYY

Witt Eye Centers Patient Registration

Patient Information

Responsible Party - patients under the age of 18 cannot be guarantor

Primary Insurance

Secondary Insurance