communityeyecarespecialists.com - Patient Demographic Information

Patient Demographic Information
Today’s Date

MonthDayYear
Name

Last NameFirst NameMI
Gender

MF
Address

Street Address

Street Address Line 2

CityState

Zip
Birth Date

MonthDayYear
Date
Age
Social Security
Marital Status
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
Preferred Language
Preferred contact method

PhoneTextEmail
Preferred contact number

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

YesNo
Are you under Hospice Care?

YesNo
Are you a diabetic?

YesNo
I authorize Community Eye Care to email or text me regarding appointment reminders

YesNo
I authorize Community Eye Care to email or text me regarding appointment reminders
I do not want to receive appointment reminders via email or text message and revoke any previous authorization to do so. I understand I will receive reminders by phone call only.
I do not want to receive appointment reminders via email or text message and revoke any previous authorization to do so. I understand I will receive reminders by phone call only.
I have read and agree to Community Eye Care’s Communication Agreement
Signature

Clear
(Patient initial)
Witness

Clear
Witness
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

Area CodePhone Number
Disabled?

YesNo
Explain
Race
Ethnicity
Religion
Emergency Contact (nearest relative or friend):
Name
Relationship
Phone

Area CodePhone Number
Address
Cell / Work No.

Area CodePhone Number
If under 18, please provide the following guarantor information:
Name of Parent/Guardian
Relationship
Phone

Area CodePhone Number
Social Security Number
Date of Birth

MonthDayYear
Date
Address (if different from above)
Name

Last NameFirst NameMI
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 TimeInsurance / Billing informationTest, lab, and biopsy resultsPlan of TreatmentMedications
To the following person(s): (check all that apply):
Parent

YesNo
Name
Spouse

YesNo
Name
Significant Other:

YesNo
Name
Adult Children:

YesNo
Name(s)
Other

YesNo
Name(s) / Relationship(s)
I give permission for messages to be left on my answering machine:

YesNo
I have read and understand Community Eye Care Specialists' Notice of Privacy Practices

Clear
(Patient initial)
I have read and agree to Community Eye Care Specialists' Financial Agreement

Clear
(Patient initial)
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 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 agreement will remain in effect until revoked by me in writing.
I have read and understand the above financial statement

Clear
(Patient Signature)
Should be Empty: