Little Rock Eye Clinic, LLP

Date______PATIENT REGISTRATION BAR CODE

Patient name______

Street Address______Date of Birth______Race______Language______

City______State_____Zip______SS#______

Marital Status______Sex _M_FPerson to contact in case of Emergency

Home ph______Cell______relationship______Ethnicity (circle one)Latino/Hispanic or Non Hispanic/Latino ______Phone______

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Please write corrections above this line/ or check NO CHANGE SINCE LAST VISIT ______

ARE YOU HERE FOR AN INJURY FROM WORK? __Yes__No

DO YOU HAVE A WORK AUTHORIZATION ___Yes___No EMPLOYER______phone______City/State______

PRIMARY INSURANCE ______Address______

Ins. card scanned ___Yes___No

SECONDARY INSURANCE______Address ______

Ins. card scanned___Yes____No

VISION INSURANCE______Address______

Ins. card scanned___Yes____No

I AGREE TO THESE POLICIES;

  1. If my insurance requires a referral or authorization, I will make sure this is available for this date of service. If this is not current I will be responsible to pay all charges today.
  2. I hereby understand an authorize Little Rock Eye Clinic, LLP its Physicians or agents to apply for benefits on my behalf for services rendered to me. I request payment from my insurance carrier to be made directly to Little Rock Eye Clinic, LLP. I certify that the above information is correct and further authorize the release of any information for any claim to my insurance carrier.
  3. I understand the Little Rock Eye Clinic, LLP Privacy Policy and HIPPA compliance regulations and agree to them. I also authorize Little Rock Eye Clinic, LLP, its physicians and agents to disclose any part of or all of the medical records to my Insurance carrier. I also understand that it may be necessary to contact my present and past employer(s) in regard to Insurance claims. (copy can be obtained at the Front Desk)
  4. Guarantee of payment/non-covered charges: I, undersigned, understand that I am financially responsible for all charges Including those not covered by my health insurance and/or Medicare. I further understand that Medicare and /or my health insurance company may not cover all services rendered, such as refractions, routine eye exams, eyeglasses,Contact lenses and ancillary testing. Charges for these services may be obtained prior to the examination. I understand if Medicare and/or my insurance company deny services, then it will be my responsibility to pay for these charges.
  5. I agree to pay CO-PAYS on the date of service.
  6. I agree to allow Little Rock Eye Clinic, LLP to electronically send my prescriptions to the pharmacy of my choice and to access my medication history available from that pharmacy.

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Signature of Responsible PartyDate

Minors cannot sign this form. A minor’s parent or guardian must be present to give consent to treatment, the purchase of Eyewear, payment of charges and authorization to release medical information.

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Signature of Parent or GuardianDate