Returning Patient Paperwork

Patient Information
Name *

First Name Last Name
Date *

Month Day Year
Date
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone *
Sex *
Age *
Cell Phone *
Marital Status *
Social Security # *
Date of Birth *

Month Day Year
Date
Referred by *
Email Address *
Employer *
Occupation *
Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone
Extension
Insured's Name *
Insured's Phone *
Insured's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insured's Employer *
Insured's Occupation *
Insured's Work Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insured's Social Security # *
Insured's Date of Birth *
PERSON TO NOTIFY IN CASE OF EMERGENCY
Name *
Relationship *
Phone *
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Care Physician's Name *
Address *
Phone *
I will be paying today by: *

Cash Check Credit Card Insurance
PLEASE READ CAREFULLY AND SIGN

I understand that every visit my eyes will be dilated. I
understand that it is legal to drive dilated, but I may be more
comfortable if I have a driver.

I understand that I am financially responsible for all charges
incurred.

I request that payment of authorized insurance benefits be
made to Retina Consultants of Nevada for any services furnished to me.

A handling fee will be charged for personal checks returned from the bank for any reason.

This consent acknowledges and permits Retina Consultants of
Nevada to use and disclose Protected Health Information (PHI) to carry out treatment, payment or healthcare operations.

Retina Consultants of Nevada contacts patients by phone call, email and/or text message.
Consent to opt-in for communication via

Email Text Message
Signature

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Date

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Date

Patient-Appointed Designate Authentication & Authorization Form
According to HIPAA and as our patient, you are entitled to privacy of your protected health information (PHI). We are required to offer you the option to appoint a person of your choice who Retina Consultants of Nevada may disclose your PHI to on your behalf. This designate would be someone who would accompany you to the office; someone who the Retina Consultants of Nevada’s healthcare team may call to relate information about you to; someone who would call in for information regarding your care and treatment. You have the right to revoke or change your choice of designate in writing, except to the extent that action has already been taken in reliance on this authorization, or if applicable, during a contestability period. In order for the revocation of this authorization to be effective, Retina Consultants of Nevada must receive the MAIL; and said revocation will not be in effect until received by said Privacy Owner.
Patient Name *
Date *

Month Day Year
Date
Designate Name *
Designate Date of Birth *

Month Day Year
Date
Patient Signature

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Date

Month Day Year
Date
Designate Name
Designate Date of Birth

Month Day Year
Date
Patient Signature

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Date

Month Day Year
Date
Designate Name
Designate Date of Birth

Month Day Year
Date
Patient Signature

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Date

Month Day Year
Date
Should be Empty:

Patient Information

PERSON TO NOTIFY IN CASE OF EMERGENCY

Patient Medical Information

Patient-Appointed Designate Authentication & Authorization Form