Consulting Ophthalmologists Information Form
ADVERTISEMENT
1CONSULTING OPHTHALMOLOGISTS, P.C.
499 FARMINGTON AVENUE, SUITE 100
FARMINGTON, CT 06032
704 HEBRON AVENUE, SUITE 200
GLASTONBURY, CT 06033
(860)678-0202
.
.
WWW
CONSULTINGEYE
COM
Name______________________________________________D.O.B._____________ Male
Female
Last
First
Middle Initial
Address_______________________________ City_____________________ State_______ Zip_____________
Phone (
)_________________ Cell Phone (
)________________Email ___________________________
Primary Language (please circle one) English, Spanish, Other (indicate)_______________ Birth State_________
Race (please circle one): American Indian/Alaskan, Asian, Black/African American, Native Hawaiian,
White, Other, or Decline to Answer.
Ethnicity: (please circle one): Not Hispanic or Latino, Hispanic or Latino, Unknown, Decline to Answer.
Social Security #__________________________ Employer________________________________________
Employer Address______________________ City__________________ State_______ Zip______________
Occupation__________________________________ Employed Since_______________________________
Reason for my visit__________________________________________
INSURANCE INFORMATION
Primary Insurance Co.________________________ Policy Holder__________________ D.O.B.____________
Primary Holder’s SS # Or ID #________________ Group #_______________ Employer__________________
Secondary Insurance Co.______________________ Policy Holder__________________ D.O.B.____________
Secondary Holder’s SS # Or ID #_______________ Group #______________ Employer__________________
REFERRAL INFORMATION
Name of Referring Party______________________________________ Phone (
)_________________
Name of Primary Care Physician___________________________________ Phone (
)________________
FINANCIALLY RESPONSIBLE PARTY – Must be completed if patient is under18 or a student.
Name___________________________ Relationship____________________ D.O.B____________________
Address___________________________ City _____________________ State________ Zip_____________
Phone (
)_________________ Cell Phone (
)_______________ Social Security #________________
AUTHORIZATION AND RELEASE: I hereby authorize payment directly to the doctor of any medical benefits otherwise payable to me. I
understand I am financially responsible to him/her for charges not covered by this assignment. I authorize him/her to release any information
requested to support my claim including any information which constitutes a psychiatric communication and/or relates to treatment of alcohol
and drug abuse.
FINANCIAL RESPONSIBILITY: This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay
for services rendered including reasonable attorney’s fees and costs of collection in the event of default.
FINANCIAL RESPONSIBILITY ACKNOWLEDGEMENT: I understand that if at any time my insurance plan does not cover my services I
agree to pay all charges.
Signature_______________________________________ Date:_______________________________
OFFICE USE ONLY
ACCOUNT NUMBER
DR. CODE
DOCTOR
OFFICE USE ONLY
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical