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Demographics


Patient Information
TitleFirstLastMISuffixNickname
Address:
City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
Cell Phone: Preferred Contact Method:
SSN Email
Birthday Occupation
Sex Employment Status
Marital Status Employer / School Name
Misc/Guardian



Vision

Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Medical

Primary Medical Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:
Secondary Medical Insurance Information
Insurance Name:
Insurance Plan:
Insurance ID:
Insurance Policy Group:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First, MI
Relationship to Insured:
Sex:
Address:
City: State: Zip:
Phone Number:
Birthday:
SSN:
Employer/School:

Policies and Submit Data


ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

The law requires that 1st Eye Care make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:



Please list the names of persons with whom you authorize 1st Eye Care to communicate regarding your medical care and financial records. If no names are listed, 1st Eye Care is not authorized to release any information of any kind to family or friends on your behalf.

Name: Relationship:
Name: Relationship:

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.

Signature: DOB: Date:

If you are signing as a personal representative of the patient, please indicate your relationship.

Representative: Relationship to Patient:

PATIENT AUTHORIZATIONS OF RELEASE

I hereby authorize my doctor to release to my insurance carriers any medical or other information needed for all services I receive. I request all insurance payments be made directly to my doctor. I understand that if my insurance company does not pay within 45 days or decides that a service is "non-covered" that a bill will be sent directly to me. I further understand that I am responsible for any deductible, coinsurance, co pays and refraction fees at the time of service.

I understand that, if at any time, I change my insurance coverage to a managed care plan or change my primary care physician, I am responsible for notifying your office of such changes. If I fail to notify the office or fail to obtain a valid referral prior to my visit, and decide to be seen by 1st Eye Care, I understand that my services may not be covered by my insurance company and I will be responsible for all charges incurred.

I understand that if I do not have any insurance coverage, I am responsible for all charges at the time of service.

I understand that all re-examinations are subject to a re-exam fee that may not be covered by my vision insurance.

I understand that I have the right to purchase products and request that they be made by 1st Eye Care instead of my vision insurance company.

Patients who do not keep their appointments or provide 24 hour notice of cancellation will be subject to a charge of $50.00

I authorize 1st Eye Care to contact me via email, text, or phone regarding any further appointments.

Signature: Date: