Confidential Patient Information
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4Patient Name: ________________
Account #: ___________________
EYE & ASSOCIATES
CONFIDENTIAL PATIENT INFORMATION
Patientʼs Name: ___________________________________________________
" Date: ______________
Sex:
M
F" "
"
Date of Birth: ____________________________"
Age: ______________
Home Address: ____________________________________________________"
Apt: # ______________
City: ____________________
State: __________________________________"
Zip: _______________
Home Phone Number: _________________________"
"
Cell/Alternate: ___________________________
Email Address: _______________________________
"
May we occasionally email you?
Y
N
Social Security Number: ________________________
"
Driverʼs License Number :__________________
If Child, parentʼs/guardianʼs name: ______________________________________________________________
Primary Care Physician: _______________________
"
Referring Physician: ______________________
How did you hear about our office? !
Commercial"
Jaguar Stadium
Family/Friend
Internet
Insurance Handbook
Other: ______________
Primary Insurance: _______________________"
"
Secondary Insurance: ___________________
Policy #: ________________________________"
"
Policy #: _______________________________
Policy Holderʼs Name: _____________________
" "
Policy Holderʼs Name: ____________________
Would you like us to communicate to any other family members, Power of Attorney, or other individuals pertaining
to your medical records, treatment plan, billing/insurance questions, appointments, etc.? If so, please list below.
Name :_________________________________ "
"
Relation to You: ________________________
Patient HIPPA Consent:
In each of our offices, we have our Notice of Privacy Practices published. This Notice contains a Patient Rightʼs Section describing your
rights under the law. You have the right to review our Notice before signing this consent. The terms of our Notice may change. If we
change our Notice, you may obtain a revised copy by contacting our office.
You have a right to request how protected health information about you is used or disclosed for your treatment, payment, and health care
operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about your treatment, payment, and health
care operations. You have the right to revoke this consent, in writing, signed by you at any time; however, that does not affect any
disclosures we have already made in reliance with your prior consent. This consent is required so that Bowden Eye is in compliance with
the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
Patient Signature: ___________________________________ !
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Staff Initials: ________________
Relationship if other than patient: ______________________
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Parent category: Medical