Patient Information Form printable pdf download

Name:

Age:

Chart:

DOB:

Date:

Referring Dr:

HAIK HUMBLE EYE CENTER

last name

first name

middle

maiden name

home phone

Patient Information

street address/p.o. box/route

city

state

zip

social security number

date of birth

age

sex

Race:

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Ethnicity:

Asian

White

Hispanic or Latino

Black or African American

Other

Not Hispanic or Latino

cellular phone

email address

Primary Language:

employer name and occupation

English

Other

employer address

city

state

work phone

workman's compensation?

yes

marital status

spouse's name

spouse's social security #

spouse's birthdate

spouse's work phone

spouse's employer and occupation

spouse's employer address

city

state

zip

How will you pay for today's visit?

Payment / Insurance

Medicare

Medical Insurance

Vision Insurance

Self-Pay

Worker's Comp

Information

medicare number

medicaid number

medicare supplement

policy number

insurance company

policy number

group number

name of insured

last name (father)

first name

middle

phone

Guarantor Information

(for children)

billing address/p.o. box/route

city

state

zip

social security number

date of birth

employer

occupation

work phone number

last name (mother)

first name

middle

maiden name

phone number

billing address/p.o. box/route

city

state

zip

social security number

date of birth

employer

occupation

work phone number

Name of relative or friend

name

relationship to patient

(not in same household)

address

city

state

zip

phone number

Referred By:

Please indicate who referred you so we may thank them.

Family/Friend

Radio

Newspaper

Yellow Pages

Billboard

Website/Internet

Direct Mail

Nurse Practitioner_____________________

Other____________________

Doctor________________________

referring person or doctor's name

Has any member of your family ever been treated by our clinic?

yes

don't know

name(s): ________________________________

Please read the following statements and sign:

I authorize release of medical information. I consent to photography. This authorization shall be binding indefinitely from the date of signature. A copy of

this release will be as legal and binding as the original.

I understand all office visits are to be paid at the time services are rendered. I also realize that I am responsible for payment before filing my insurance. For

any services rendered I request that payment of authorized Medicare, Medicaid, or insurance benefits be made to Eye Associates of Northeast Louisiana,

Surgery Center of West Monroe, Raymond Haik MD, Joseph Humble MD, Thomas Parker MD, Baron Williamson MD, Ruben Grigorian MD, Jonathan Scogin OD,

Jim Eaton OD, Robert Pierce OD, or Thomas Marsala, PA-C. I authorize any holder of medical or other information about me to release to the Health Care

Financing Administration, insurance company and its agents any information needed to determine these benefits or benefits for related services.

A monthly interest charge of 1 1/2% per month (18% annually) may be added to all past due accounts (over 60 days). Any account with a pending

balance over 90 days may be referred for collection.

Due to danger to myself and others, I realize I should not drive while my eye is dilated, medicated, or patched.

Signature of patient or guardian:

Date: