Patient Information Form

Patient Information & Insurance Information
Patient Information
Name *

First Name Last Name
Preferred Name
Date of Birth *

Month Day Year
Date
Sex *

Male Female
Gender
Address *

Street Address

Street Address Line 2

City State

Zip Code
Cell Phone

Area Code Phone Number
May we text you?

Yes No
Home Phone / Landline

Area Code Phone Number
May we leave messages with a family member?

Yes No
May we leave messages on your answering machine?

Yes No
Email Address
What is your preferred method of contact for reminders? *

Text Email Home Phone
Last 4 Digits of Social Security Number
Required in order to submit Vision Insurance Claims
Marital Status *
Employment Status *
Employer
Occupation
Billing Information (Responsible Party)

Fill out if different than Patient Information.
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State

Zip Code
Vision Insurance Information

Note: We participate with VSP and most self-funded Vision Plans as an In-Network Provider. We are Out-of-Network Providers for all other Vision Insurance plans.
What type of Vision Insurance do you have? *

I don't know None Vision Service Plan (VSP) EyeMed Spectera/United Healthcare Vision Superior/Versant
Medical Insurance Information
Enrollee Name

First Name Last Name
Date of Birth

Month Day Year
Date
Sex

Male Female
Address

Street Address

Street Address Line 2

City State

Zip Code
Last 4 Digits of Social Security Number
Required in order to submit Vision Insurance Claims
Employer
Routine vision exams will be filed with a patient's vision plan if one is available and we participate. A routine vision exam means there is a vision diagnosis, in the absence of a medical diagnosis. Vision diagnoses include myopia (near-sightedness), hyperopia (far-sightedness), astigmatism, and presbyopia.

If a Medical Diagnosis (cataracts, glaucoma suspect, foreign body, diabetes, dry eye, etc) is determined by the doctor, the patient's exam is no longer routine, but medical. This means we will bill your medical health insurance and collect your medical copay and/or deductible which is required at time of service. We request a copy of your medical card in your chart for this reason.

Please take photos of front AND back of insurance card OR scan and upload images of both sides of your insurance card below:
Option 1: Take Photo of Front of Medical Insurance Card
Option 1 (continued): Take Photo of Back of Medical Insurance Card
Option 2: Upload Image of Front of Medical Insurance Card

Browse Files

Cancel of
Option 2 (continued): Upload Image of Back of Medical Insurance Card

Browse Files

Cancel of
- I understand my insurance may pay less than the actual billed amount for services. I agree to be responsible for payment of all services rendered on my behalf or on the behalf of my dependent.
- I give Richland Eye Care permission to bill my insurance for eye care services and/or products. I hereby authorize my insurance benefits to be paid directly to Richland Eye Care.
- By signing below, I agree that I have read and understand all of the above information. This signature will also serve as record of my "Signature on File" that insurance companies require for claim processing.
Signature of patient/guarantor *

Clear
Relationship if not patient
Acknowledgment - Receipt of Notice of Privacy Practices

By signing this form, you are acknowledging that you have been offered a copy of Richland Eye Care's Notice of Privacy Practices, effective 2020:
Patient Signature (or Signature of Parent/Guardian if Patient is a Minor) *

Clear
If you are signing on behalf of the patient as a Parent or Guardian, please enter your name and relationship to the Patient below:

First Name Last Name
Relationship
Should be Empty:

Patient Information & Insurance Information

Patient Information

Billing Information (Responsible Party)

Vision Insurance Information

Medical Insurance Information

Acknowledgment - Receipt of Notice of Privacy Practices