premierfamilyeyes.com - New Patient Form (Adult)

NEW PATIENT REGISTRATION

In order to provide you the best possible care, please complete this form and bring it to your first appointment. All information is strictly CONFIDENTIAL.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone
Please enter a valid phone number.
Mobile Phone
Please enter a valid phone number.
Email
example@example.com
Patient Information
Gender
Date of Birth

MonthDayYear
Date
Last Digits of SSN
Insurance Information
Provider Name (Primary)
Policy/I.D. No. (Primary)
Group No. (Primary)
Provider Name (Secondary)
Policy/I.D. No. (Secondary)
Group No. (Secondary)
Financial Assignment Information
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Acknowledgment of Notice of Privacy Practices (NPP)
I authorize Premier Family Eyecare to release any Information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eyecare to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to Premier Family Eyecare. Visions plans only cover routine vision exams, along with eyeglasses and contact lenses. Vision plans to do not cover medical care (diagnosis, management or treatment of eye health problems) including cataracts, glaucoma, and dry eye to name a few. I understand if fees are not paid by my insurance, I am responsible for all uncovered services. Accounts over 90 days are subject to collections and returned checks have a service charge of $35.00 in addition to the outstanding balance.

HIPAA NOTICE OF PRIVACY POLICIES: I UNDERSTAND I MAY OBTAIN A COPY OF PREMIER FAMILY EYECARE'S NOTICE OF PRIVACY PRACTICES UPON

REQUEST HEALTH RELATED COMMUNICATIONS AND REMINDERS: I PERMIT PREMIER FAMILY EYECARE TO COMMUNICATE AND REMIND ME ABOUT MY HEALTH RELATED ISSUES AND APPOINTMENTS BY PHONE, TEXT, AND/OR EMAIL
Signature agreeing to all above terms

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Date

MonthDayYear
Date