Communityeyecarespecialists- Patient Information Form

Today’s Date

Name

First Name Last Name

MI

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Sex

M F

Birth Date

Age

Social Security

Marital Status

Married Divorced Single Widowed Separated

Home Phone

Cell Phone

Email

example@example.com

Preferred Language

Preferred contact method

Phone Text Email

Preferred contact number

Home Cell

I authorize Community Eye Care to email me regarding appointment reminders and patient portal set up

Yes No

I authorize Community Eye Care to text message me regarding appointment reminders

Yes No

I have read and agree to Community Eye Care’s Communication Agreement

Signature

(Patient initial) Clear

Witness

Witness Clear

OR

I do not want to receive appointment reminders by e-mail or text message and revoke any previous authorization to do so. I understand I will receive appointment reminders by phone call only.

Family Doctor

Referring Physician

Employer

Occupation

Work

Disabled?

Yes No

Race

Ethnicity

Religion

Who to notify in an Emergency (nearest relative or friend):

Name

Relationship

Phone

Address

Cell / Work No.

If under 18, please provide the following guarantor information:

Name

Relationship

Home

Social Security Number

Date of Birth

Address (if different from above)

Permission to Release Information
I authorize the physicians and staff of Community Eye Care Specialists to release my medical information as follows. I understand that this remains effective until such time that I inform the practice and complete another written form.

I authorize the release of (check all that apply)

Appointment Time Insurance / Billing information Test, lab, and biopsy results Plan of Treatment Medications

To the following person(s): (check all that apply):

Yes

No

Spouse

Significant Other:

Adult Children:

Other

I give permission for messages to be left on my answering machine:

Yes No

I have read and understand Community Eye Care’s Notice of Privacy Practices

(Patient initial) Clear

I have read and agree to Community Eye Care’s Financial Agreement

(Patient initial) Clear

It is your responsibility to pay any deductible amount, co-insurance, or any balance not paid for by your insurance. I request that payment of authorized insurance benefits be made on my behalf for any services furnished to me. I authorize any medical information about me to be released to the Health Care Financing Administration, its agents, or any insurance carrier I may have, including any information needed to determine these benefits or the benefits payable for related services. I understand that I am financially responsible for all charges whether or not paid by said insurance. This assignment will remain in effect until revoked by me in writing.

Please sign that you have read and understand the above

(Patient Signature) Clear