Patient Information Form printable pdf download

VISTA LINDA EYE CARE, INC. PATIENT INFORMATION

REV 5.20.14

ODAY’S

ATE

ATIENT

AME(s)

ATE

IRTH:

____________________________________________________________

SOCIAL SECURITY # ______-_____-______

OCCUPATION: ______________________________

SOCIAL SECURITY # ______-_____-______

____________________________________________________________

OCCUPATION: ______________________________

ATE

IRTH

SOCIAL SECURITY # ______-_____-______

____________________________________________________________

OCCUPATION: ______________________________

ATE

IRTH

ADDRESS

E-MAIL:

_____________________________________

CITY, STATE, ZIP: ____________________________________________________

EMPLOYER:

_________________________________

HOME PHONE #

_______________________________________________

WORK PHONE #

______________________________

CELL PHONE #

________________________________________________

MERGENCY

ONTACT

IF PATIENT IS A MINOR,

Name: ____________________________________

RESPONSIBLE PERSON’S NAME: ______________________________

RESPONSIBLE PERSON’S SSN:

________ - ______ - _________

Telephone: ________________________________

: __________________________________________

REFERRED BY

Updated in Computer __________ initials

Acknowledgement of Receipt of Notice of Privacy Practices (HIPAA)

Signature of patient or patient(s) representative:_____________________________________________________________

Relationship to patient(s) : ___________________________________________

Medical Release Authorization and Insurance Assignment:

I, the undersigned, authorize payment from my insurance company to be made to Vista Linda Eye Care, Inc. for covered services. I understand that I am

responsible for obtaining any referrals needed before my appointment or I must pay for that visit. Regardless of my insurance status, I am

ultimately responsible for the balance on my account.

Should timely payments of this account not be made, I authorize Vista Linda Eye Care, Inc. to retain the services of an attorney and/or collection agency to

assist with the collection of any outstanding balance. Any expenses incurred by such an action shall become an additional liability for which I am

responsible.

I certify that the information I have provided with regard to my insurance coverage is correct and further authorize the release of any necessary information,

including medical information, to my insurance company in order to determine insurance benefits to which I may be entitled. This authorization may be

revoked by myself at any time in writing.

___________________________________________

Print Name

Signature

Date