Patient Registration Packet

Patient Registration Sheet
Title*

Mr.Mrs.MissMs.
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Cell Phone*
Work Phone*
Email*
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Social Security #
Referred by (how did you hear about us?)*
Patient's Family Physician*
Patient employed by*
Occupation*
Retired?*

YesNo
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Name
Spouse Employed by
Phone Number
Emergency contact not living with you*
Relationship*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance with*
Policy #*
Secondary Insurance with
Policy #
Policy Holder Name*
DOB*
Social Security Number*
Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization to Pay Benefits To Physician: I authorize the release of medical or other information necessary to process health insurance claims. I also request payment of benefits to myself or to The Wright Eye Center when they accept assignment.

Authorization to Release Medical Information: I hereby authorize The Wright Eye Center to release any information necessary for my course of treatment and photocopies of this form are valid as the original.

Authorization of Responsibility: I understand I am ultimately responsible for services rendered even though I may be covered by medical, workman’s compensation, or a private agreement with another party.

Notice of Privacy Practices: By my signature I acknowledge that I have received a copy the Notice of Privacy Practices from The Wright Eye Center/Natural Eyes Laser and Surgery Center.
Signature

Clear
Date

Patient Medication
Medications currently taking (including all non-prescription, over-the-counter, vitamins and herbal)
Please list any allergies you might have
I HAVE NO MEDICATION ALLERGIES
Allergic to Latex*

YesNo
Allergic to Tape/Adhesive*

YesNo
By signing this form I verify that there have been no changes or I have made the correct changes to my current medications/allergies:
Signature

Clear
Date

MonthDayYear
Date

Financial Policy and Patient Agreement
The following is the financial policy of THE WRIGHT EYE CENTER, which you are required to read and sign prior to treatment:

PAYMENT IS DUE AT THE TIME OF SERVICE. Acceptable forms of payment are cash, check, Visa, Master Card, and Discover. All co-pays will be collected at the end of your visit.

Most insurance companies do not cover routine eye care and eye refractions. Payment for non-covered services will be collected at the end of your visit. If you have questions about whether your insurance pays for routine eyecare, please ask to speak to our Patient Financial Services Office before your appointment.

INSURANCE FILING. Payment for health care services is your responsibility. As a courtesy to you, we will bill your primary insurance. However, in the event your insurance claim is rejected, THE WRIGHT EYE CENTER is not a party between you and your contracted insurance company. Accordingly, it is your personal responsibility to follow up with your insurance carrier to determine the reason for claim denial. We will only bill your secondary insurance when your physician is participating provider with your secondary insurance carrier.

HMO/PPO. All co-payments and deductibles are due and payable at the time service is provided. You are required to obtain a referral from your primary care physician prior to your appointment. You are responsible for verifying with your insurance carrier that the primary care physician referral has been approved.

MEDICARE. We will bill Medicare for you. We do accept Medicare assignments. All co-payments and deductibles are due and payable at the time service is provided.

MEDICAID. A current Medicaid card must be presented at the time of service, otherwise, your appointment will be rescheduled dependent upon the availability of a valid card.

WAIVER OF MEDICAL NECESSITY. Many insurance companies will deny payment for testing and/or surgical procedures performed by your physician as not medically reasonable or necessary. In some cases, the insurance company may deny payment for the medical service (s) rendered. You agree to be responsible for payment of all medical services. Any medical service not paid for by your existing insurance coverage will require payment in full as services are provided or upon notice of insurance claim denial.

QUESTIONS ABOUT YOUR ACCOUNT
We pride ourselves on the care our patients receive and the high level of satisfaction our patients experience following treatment by both the Physicians and Clinical Staff at WRIGHT EYE CENTER. Our Business Office Staff is equally dedicated to helping you at any time. Please ask our staff about any policy or procedure that you do not understand. Questions may also be directed to the Patient Financial Services office by calling (719) 634-0515.

By signing this agreement, I authorize the release of medical information relating to my care to my insurance company. I authorize insurance payments to be made directly to THE WRIGHT EYE CENTER.

Special financial arrangements must be made prior to service with an addendum to this document.

Patient Agreement:

I have read and understand the financial policy as defined and agree to the terms as stated.
Patient Name*

First NameLast Name
Signature*

Clear
Patient Social Security Number*

Telephone Messaging Information
From time to time in caring for our patients, it may be necessary to contact patients by telephone. When you are not available to speak to us directly, we like to leave messages where possible.

In order to protect your privacy, it is The Wright Eye Center’s/ Natural Eyes Laser and Surgery Center policy that:

1. We WILL NOT leave messages with anyone except the patient.
2. We WILL NOT leave any information on an answering machine.
3. We WILL NOT leave any messages on a voice mail system.

UNLESS WE HAVE YOUR WRITTEN PERMISSION TO LEAVE MESSAGES FOR YOU.

Please read the information below and consider carefully whom you want to have access to your medical
information related to your eye care.
I,
Patient Name
give The Wright Eye Center/ Natural Eyes Laser and Surgery Center and its office staff my permission to leave telephone messages containing medical and/or financial information on an answering machine/voice mail.
At Home*

YesNo
Phone Number
At Work*

YesNo
Phone Number
On Cell*

YesNo
Phone Number
DO NOT LEAVE ANY MESSAGES*

YesNo
Patient Initials*
** Appointment Reminders may be left on your answering machine/ voicemail if you answer no.

I give authorization to the doctors and/or staff at The Wright Eye Center/ Natural Eyes Laser and Surgery Center to discuss medical and/or financial information with the following people:
Name
Relationship
Phone Number
Name
Relationship
Phone Number
Name
Relationship
Phone Number
I understand it is my responsibility to inform The Wright Eye Center/ Natural Eyes Laser and Surgery Center of any changes in this authorization.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Registration Sheet

Patient History

Family History

Patient Medication

Financial Policy and Patient Agreement

Telephone Messaging Information