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How did you hear about us?
If friend/family who:
Do you wear contact lenses?
Do you want an exam to become a contact lenses wearer?
Do you wear glasses?
Do you want new glasses today?
Are you interested in talking to the doctor about LASIK?
What is your preferred method of contact?
(Used for appointment reminders and glasses/contacts pickup reminders)(We will never give out your Email or Phone numbers)
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Patient's Last Name
Primary Care Physician
RESPONSIBLE PARTY INSURED
Policy Holder name
Relationship to Insured
Same as patient
Is the patient covered by any other Medical/ Vision insurance policy?
If yes, name of insurance
Assignment of Benefits: I agree to have my insurance send all payments for services rendered at Price Eyecare & Optical directly to the office on the claim form. Furthermore, I agree to have any medical records copied and sent to my insurance company to facilitate getting a claim paid and processed. This assignment may be copied and used the same as an original document. By signing the below, I acknowledge that all information is true and that I am compliant with the assignmnet of benefits. HIPAA- Patient Privacy Act* I hereby acknowledge that I received a copy of this medical practice's NOTICE OF PRIVACY PRACTICES. I further acknowledge that a copy of the current notice is posted in the reception area, and I will be offered a copy of any amended notice of Privacy Practices at each appointment.
Member ID, SSN and DOB will need to be provided at time of check-in.
(ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES (HIPAA)