Existing Patient Packet

Existing Patient Packet

Annual update
Full Legal Name*

First NameMiddle NameLast Name
Birthdate*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
Do you consent to Idaho Eye and Laser Center to communicate with you via email, text or voicemail regarding personal health information?*

YesNo
RELEASE OF INFORMATION: Do you authorize the Idaho Eye and Laser Center to share and/or receive medical information with the following person(s):*

YesNo, do not disclose my information to any person(s)
Please list name of persons authorized to receive information regarding my medical care and your relationship.
Example: John Doe / Spouse
Financial Policy

Please let us know if you insurance information has changed.
ACKNOWLEDGEMENT:

By reading and signing this form I accept my rights and responsibilities as a patient and consent to the treatment and services provided by Idaho Eye Center. I authorize the release of any medical information necessary to process the bill to my insurance company and request payment of benefits to Idaho Eye and Laser Center. I acknowledge that I am financially responsible for payment whether or not covered by insurance. I acknowledge that this authorization has no expiration date and is valid until revoked.
Signature*

Clear

Financial Policy