glaucomacenter.net - Established Patient Annual Medical Update

Annual Medical Update and Insurance Assignment and Release 2026
Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a voice message with medical or insurance information
How would you like to receive appointment reminders
How would you like to receive billing statements?
Email address
example@example.com
Primary Care Physician Name
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Emergency Contact
Relationship to patient
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Release of Information: As a patient of The Glaucoma Center, LLC, we are obligated to protect your health information. By law, we cannot discuss your health information with anyone but you unless we have written consent that authorized us to do so. If you have family and/or friends that you want us to share your personal health information with, please list them below. A child's (under age 18) health information may be discussed with their legal parent or guardian without a signed authorization.
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Information: You are responsible for providing a referral from your PCP (if required by your insurance) at the time of service.
Primary Insurance
Secondary Insurance
Subscriber name if other than patient
DOB

MonthDayYear
Date
Co-payments or deductible amounts are to be collected at the time services are received. You will be responsible for any balance deemed patient responsibility/non-payable/non-covered by your insurance and billed accordingly. Payment is expected in full upon receipt of statement or payment arrangements must be made with our billing office.

We ask that you show consideration by notifying our office at least 24 hours in advance if you are unable to keep an appointment. If you fail to give us a 24-hour notice of cancellation, there will be a $50 cancellation fee billed to your account that is non-covered by your insurance. You will bear complete financial responsibility for this fee.
Insurance Assignment and Release: I hereby authorize my insurance benefits to be paid directly to The Glaucoma Center, LLC. I understand that I am responsible for all charges including any added costs incurred due any effort to collect for services rendered. I acknowledge that I am responsible for paying for non-covered services and I hereby authorize the release of pertinent medical information to insurance carriers.

I authorize The Glaucoma Center, LLC to release my medical and/or billing information to those I have indicated in my release of information. I understand I have the right to revoke this authorization at any time. This form has been fully explained to me and I understand its contents.
Patient/Guardian Signature
Date

MonthDayYear
Date
Medical History Annual Update
Name
DOB

MonthDayYear
Date
REVIEW OF SYSTEMS

Do you presently have any problems in the following areas? If YES, give an explanation.

EYES

Rows	YES	NO	Explanation
Loss of or blurred vision
Itching, burning, or discharge
Redness
Gritty feeling/dryness/tearing
Glare/light sensitivity/halos
Infection of lids or styes

Are you allergic to any medications?
Allergic to
If yes, please list
PRESENT ILLNESS
Has anything changed medically over the past six months?
Explanation
VACCINATIONS
MEDICATIONS
Please list all medications that you are currently using
Advanced Care Planning

Do you have a health care agent? This is a family member or a friend who is able to speak on your behalf if you are in a limited capacity or not able to make medical decisions for yourself. Please list your health care agent if you have someone designated:
Name
Relationship
Patient Signature
Date

MonthDayYear
Date
Should be Empty:

Annual Medical Update and Insurance Assignment and Release 2026

Medical History Annual Update

REVIEW OF SYSTEMS

PRESENT ILLNESS

MEDICATIONS