Demographic Form

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Patient Name *

Date of Birth *

Sex

Male
Female

Home Street Address

Apt. #

City

State

Zip

Home Phone

Work Phone

Cell Phone *

Email Address *

Emergency Contact

Phone

Referring Physician

Phone

Primary Care Physician

Phone

Primary Insurance Company Name

Primary Insurance Group #

Primary Insurance ID #

Name of Policy Holder (Primary Insurance)

Policy Holder Date of Birth (Primary Insurance)

Relationship to Patient (Primary Insurance)

Secondary Insurance Company Name

Secondary Insurance Group #

Secondary Insurance ID #

Name of Policy Holder (Secondary Insurance)

Policy Holder Date of Birth (Secondary Insurance)

Relationship to Patient (Secondary Insurance)

Person Financially Responsible for Account (if other than patient):

Name

Date Of Birth

Relationship to Patient

Billing Address :

Street

Apt.#

City

State

Zip

Home Phone

Work

Cell

ASSIGNMENT OF BENEFITS : *

By checking this box, I acknowledge that I have read and understand the below information.

I request payment of authorized Medicare and/or Insurance carrier benefits be made on my behalf to Capital Eye Care for any service furnished to me by Capital Eye Care’s physicians. I authorize my physician to release to Medicare and/or my Insurance carrier(s) any information needed to determine these benefits or the benefits payable for related services. I agree to provide all referrals as required by my insurance carrier(s). I recognize my responsibility to guarantee the accuracy of the insurance information I have provided. I agree that all claims that are not paid within 60 days as a result of incorrect insurance information provided by me (not errors on part of provider claim submission) will become my financial responsibility. I understand any unpaid balances and non-covered services are my financial responsibility. Capital Eye Care reserves the right to charge a $25.00 service fee for any unpaid balances including co-pays and deductibles that are due at the time of service. I understand I will be charged a missed appointment fee of $50.00 per visit should I fail to provide 24 hours notice of cancellations or rescheduling. I also understand I will be charged a $35.00 fee for any returned check. Should my account be turned over to a collections agency, I understand that I will be charged for all collection and or attorney and court fees.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT: *

By checking this box, I acknowledge that I have read and understand the below information.

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. • Obtain payment from third party payers. • Conduct normal healthcare operations such as quality assessments and physician certifications. • Authorize third party to verify insurance benefits and eligibility. I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.