WELCOME TO THE FAMILY EYECARE CENTER

PATIENT INFORMATION

 

NAME ______________________________________   MR    MRS    MS    MISS    DR

                  LAST                    FIRST                        INITIAL

 

TELEPHONE # ______________ CELL PHONE # ____________ DATE OF BIRTH _______

 

MAILING  ADDRESS  _______________________________________________________________

 

PHYSICAL ADDRESS(IF DIFFERENT THAN MAILING ADDRESS) __________________________________

 

MARITAL STATUS     S___ M___ D___ W___   GENDER     M    F     SS# ______________

 

DATE OF LAST EXAM __________________    WHERE  __________________________

 

E-MAIL ADDRESS ________________________________________________________

MAY WE CONTACT YOU BY E-MAIL OR TEXT?       YES        NO

 

ARE YOU EMPLOYED?         YES         NO                      FULL-TIME STUDENT      YES        NO

EMPLOYER/SCHOOL NAME ______________________________ WORK # __________

 

OCCUPATION _____________________ EMPLOYER ADDRESS ____________________

 

PERSON RESPONSIBLE FOR PAYMENT

___PATIENT ___SPOUSE ___PARENT ___LEGAL GUARDIAN(POWER OF ATTORNEY COPIES)

 

SPOUSE/GUARDIAN/PARENT  ______________________________________________

                                                                       NAME                                                       ADDRESS

 

DATE OF BIRTH  _______________________ SOCIAL SECURITY # _________________

 

NAME OF EMPLOYER  ____________________________________________________

 

EMPLOYERS ADDRESS  ____________________________________________________

 

WORK PHONE # _________________________  CELL PHONE # ___________________

 

METHOD OF PAYMENT – PAYMENT EXPECTED ON DATE OF SERVICE

 

_____ CASH               _____  CHECK             _____  CREDIT CARD           _____INSURANCE

 

                                                                                        ___________________________________________

                                                                                                   SIGNATURE   

 

——————OVER——————

INSURANCE INFORMATION

 

____MEDICARE   ____ MEDICAID     ____CHIP     ____VSP      ____OTHER   ____ NONE

 

PRIMARY INSURANCE CARRIER _____________________ INSURED NAME _________

 

GROUP # ___________ INSURED ID# ____________INSURED DATE OF BIRTH _______

 

SECONDARY INSURANCE CARRIER ________________INSURED NAME ____________

 

GROUP # _________ INSURED ID # ____________ INSURED DATE OF BIRTH ________

 

 

INSURANCE PATIENTS

Medical Insurance companies do not pay for an eye exam or refraction unless a specific vision “carve out” (e.g.VSP) exists.  The patient is financially responsible for all materials and services provided by our office.  If, for any reason, the insurance company denies or ignores our first submission,  the patient will be billed and finance charges will accrue.  I also understand that all co-payments are to be paid the date of service and before materials are ordered.

(Initial Please)  _______________________                     

 

 

 

AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION (HIPAA)

 

I _________________________  authorize the Family EyeCare Center and Dr. Hyre, to release health information relating to my vision care to the following persons until I revoke the authorization in writing:

 

Relationship to Patient __________________________  Print Name ___________________________

 

Contact Phone Numbers _________________________  Print Address _________________________

 

Relationship to Patient __________________________  Print Name ___________________________

 

Contact Phone Numbers _________________________  Print Address _________________________

 

**Vision plans cannot be billed for any patient being seen with a medical eye condition.  These plans are strictly for well eye exams and do not apply if you have been diagnosed with a medical eye condition or complaints that might lead to a medical diagnosis.  Most medical insurance policies do have some coverage for medical eye diagnosis.