Prefix

Last Name

Middle Name

First Name

Street Address

City

State

Zip

Date of Birth

Marital Status

Sex

Social Security Number

Home Phone

Cell Phone

E-mail Address

Responsible Party

Phone Number

Relation to Patient

Employer

Work Phone

Work Address

Referred By

Vision Insurance

ID/Member #

Group #

Insured Name

Insured DOB

Insured SS#

Relationship to Patient

Medical Insurance

ID/Member #

Group #

Insured Name

Insured DOB

Insured SS#

Relationship to Patient

Secondary Insurance

ID/Member #

Group #

Insured Name

Insured DOB

Insured SS#

Relationship to Patient

PCP

Student

I authorize the release of any medical information necessary to process all claims and payments of medical benefits directly to my physician.

I am aware of the availability of the proctected health information for the Northwest Eye Center and their office policies for handling all such information and indicate that I was notified of the copy available in the office.

I understand that providing insurance information does not constitute payment from my insurance company. Any charges not paid by insurance will be patient responsibility.