New Patient Registration Form

Patient Information

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Primary Carrier

Secondary Carrier

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Account Information - Person Financially Responsible for Account

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Is another member of your family or relative a patient at our office? If so, please indicate their name and your relationship to them.

Your Emergency Contact - Please indicate the name, phone number, and your relationship

Closest Relative not living with you - Please indicate the name, phone number, and your relationship

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Consent for Treatment

1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of my vision needs.
2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care
3. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.
4. Last, I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In th event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (1.8% APR) may be added to my account.

I agree to the statements noted above

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AUTHORIZATION FOR SUBMISSION OF CLAIMS AND ASSIGNMENT OF BENEFITS

I authorize the health care provider named above to submit claims for payment for services to the healthcare service plans or insurance companies named below, on my behalf and in my name, and assign to such provider the group insurance benefits otherwise payable to me, but not to exceed the provider's actual charges for the covered services. I understand that I am financially responsible for any charges not covered by the group insurance benefits.

I Authorize

NOTICE OF PRIVACY PRACTICES

Click here to read the Notice of Privacy Practices. By checking the box below, you acknowledge the receipt of Notice of Privacy Practices.

I Acknowledge

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

I authorize the physician, or other health care provider named above to release to hospital or health care service plans, insurance companies, self-insurers, or their representatives, any and all information and records (including x-rays) about my medical history, or about services rendered or treatment given to me, that is needed to review, investigate or evaluate any claim for benefits.

If my coverage is under a group master agreement held by my employer, an association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or financial audit. This authorization shall remain effective for up to five years from this Date.

I know that I have the right to receive a copy of this authorization if requested.

I Authorize

HIPAA

Sign Off on HIPAA

Health Insurance Portability and Accountability Act, HIPAA provides national standards to protect the privacy of personal health information. To improve the efficiency and effectiveness of the health care system, the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191, included "Administrative Simplification" provisions that required HHS to adopt national standards for electronic health care transactions. Congress incorporated into HIPAA provisions that mandated the adoption of Federal privacy protections for individually identifiable health information.

I Agree

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After clicking the submit button, please allow 4-6 seconds for the confirmation to appear. Thank you!

8 of 8 - PLEASE MAKE SURE TO CLICK ON THE SUBMIT BUTTON

New Patient Registration Form