BBEC Demographic/Insurance Form

Demographic and Insurance Information
This information will allow us to prepare for your appointment ahead of time, including verifying any insurance policies. We appreciate your cooperation in filling this form out completely and promptly.
Full Name*

First NameLast Name
Preferred Name/Nickname
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Sex Assigned at Birth*
Preferred Pronouns

She/her/hersHe/him/hisThey/them/theirsOther
Optional: Is there a certain way you would like to be addressed by our clinic? (Example: nickname, preferred pronouns, etc.)
Last 4 digits of your social security number
Best phone number to call*
Text messaging is the easiest way for us to communicate with our patients regarding appointments, eyewear ready notifications, and balances due. May we text you at this number?

YesNo
Alternate phone number (just in case)
Please enter a valid phone number.
E-mail*
example@example.com
With your phone turned sideways, please take an up close, clear photo of the FRONT of your DRIVER'S LICENSE or ID CARD and upload it here.
With your phone turned sideways, please take an up close, clear photo of the FRONT of your MEDICAL insurance card and upload it here.
With your phone turned sideways, please take an up close, clear photo of the BACK of your MEDICAL insurance card and upload it here.
Are you the primary on the insurance policy above?

YesNo
Please list the name, date of birth, and last 4 digits of social security number of the primary insured.
Does your medical insurance require a referral to see a specialist?

YesNo
Do you have a separate vision plan? (Ex: VSP, Eyemed)

YesNoI'm not sure
Please enter the name of the vision plan you have here.
Notice of Privacy Policies
Please review our privacy policy above and sign here to acknowledge that you have reviewed it.

Clear
Please review the above document which outlines our financial policy and gives our office permission to bill your insurance, and sign below.

Clear
How did you hear about our office?

Referred by friend, family or coworkerReferred by another medical professionalDrove by/saw signGoogleInsurance directoryOther
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Demographic and Insurance Information