WELCOME TO OUR OFFICE. WE APPRECIATE YOUR HELP IN KEEPING YOUR RECORDS UPDATED.
1. Today’s Date: ___________________________________
2. Patient’s Name: _________________________________ __________________________________________ ________
Last
First
MI
3. Address: ________________ ________________________________________ __________________ ______ __________
Street/ Box/ Apt. No.
Street
City
State
Zip
4. S.S. # (
): _________-_________-_________
Needed for Insurance billing and eligibility
5. Phone Nos: Cell (______)__________________ Home (______)__________________ Work (______)________________
6. E-mail Address: _________________________________________________________________________________________
7. Date of Birth: _________ _________ _________
Sex:
M
F
8. Marital Status:
(
)
M
S
D
W
Spouse’s Name:___________________
Check
(Needed for some types of insurance)
9. Employer/Occupation: ____________________________________________________________________________________
10. Special Interests/Hobbies: (
)__________________________________________
To help us determine proper vision correction type
11. Vision Insurance Co. Name: (
):
VBA
NVA
VSP
BAI
GE
EYEMED
Check One
Other:___________________________________________________________
12. Primary Card Holder: ____________________________ Card Holder S.S.# _____________________ D.O.B. ____________
13. Medical Insurance Co. Name: (
):
Medicare
PPO Blue
BC/BS
Health America
Keystone
Check One
Select Blue
UPMC
Other:_________________________________
14. Primary Care Physician: __________________________________________ Address/Phone: ___________________________
If unsure, leave blank
PLEASE PRESENT YOUR MEDICAL AND VISION INSURANCE CARDS TO OUR RECEPTIONIST FOR COPYING.
PATIENT’S INSURANCE AUTHORIZATION/SIGNATURE ON FILE:
I request that payment of authorized insurance benefits be made to either me or on my behalf to Bayfront Eyecare for any services furnished me/my
dependent by that physician/supplier. I authorize any holder of hospital or medical information about me/my dependent to release to the above named insurance
company and its agents, any information needed to determine the benefits payable for related services. I permit a copy of this authorization to be used in place of
the original. I understand that, regardless of my insurance status, I am ultimately responsible for payment of me/my dependent’s account.
_______________________________________________________
______________________________________
Insured’s Signature
Date
I'm Done. Print!
PAYMENT OPTIONS: CASH, CHECK, MONEY ORDER OR CREDIT CARDS
OUR OFFICE ACCEPTS VISA, MASTERCARD, AMERICAN EXPRESS AND DISCOVER