Patient Registration Form - Chester County Eye Care

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(610) 696-1230
Patient Registration Form
Last Name
First
MI
Female ( )
Birth Date
P
A
Male ( )
T
Address
Apt #
City
State
Zip
I
E
N
Home Phone #
SS #
Occupation
Marital Status
T
I
Work Phone #
Cell Phone #
E-Mail
N
F
Primary Care Physician
Referring Doctor
Pharmacy Name & Phone #
O
R
M
Employer Name/Address
City
State
Zip
A
T
I
Emergency Contact
Relationship
Phone #
O
N
Primary Insurance – Name & Address
Policy #
Group #
Effective Date
Policy Holder Name
DOB
SS #
I
N
S
Relationship to Patient
Employer
U
R
A
Secondary Insurance – Name & Address
N
C
Policy #
Group #
Effective Date
E
Policy Holder Name
DOB
SS #
Relationship to Patient
Employer
Is this work related? ( ) Y
( ) N
Date of Injury
Claim #
W
K
M
Workmans Comp. Insurance & Address
N
C
O
Attorney Name & Address
M
P
UNIFORM OF ASSIGNMENT, RELEASE OF INFORMATION AND FINANCIAL DISCLOSURE:
ASSIGNMENT OF BENEFITS:
I hereby assign or transfer payment benefits made to me and by behalf to Chester County Eye Care Associates, P.C. for
any services furnished to me by this physician/supplier. I further agree that I am responsible for payment or charges
incurred by me that are not covered by my insurance or for which my insurance has paid me.
RELEASE OF INFORMATION:
I hereby authorize Chester County Eye Care Associates, P.C. to release information acquired during the course of my
examination or treatment to my referring physician, my primary care doctor, or to an appropriate insurance carrier. If
Medicare patient, I further authorize release to the Center of Medicare Services and its agents any information needed
to determine benefits payable for related charges.
[PLEASE READ AND SIGN REVERSE SIDE OF THIS FORM]

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