South Grove Eye Care PC

Patient Contact, Privacy, Consent

Patient Information

Name ___________________________________________________ Date of Birth _______________________

Address ____________________________________________________________________________________

City/State/Zip Code __________________________________________________________________________

Home phone __________________________________ Work/Cell phone _______________________________

E-mail Address ______________________________________________________________________________

SSN # (for insurance) ____________________________Occupation __________________________________

Parent/Guardian Information (if applicable)

Name ____________________________________________ Relationship to patient ______________________

Address (if different than above) _________________________________________________________________

City/State/Zip Code __________________________________________________________________________

Home phone ___________________________________ Work/Cell phone ______________________________

E-mail Address ______________________________________________________________________________

Medical Insurance Information

Name of Insurance ________________________________ Customer Service Phone_____________________

Claim Address ______________________________________________________________________________

City/State/Zip Code __________________________________________________________________________

Name of Insured _________________________DOB______________ Relationship to Patient _____________

Member ID # ______________________________________________ Group # _________________________

How did you hear of our office: (please check)

{ } Insurance Website { } Yellow Pages { } Sign { } TV/Cable

{ } Radio { } Newspaper { } Referral { } Other

I am aware of South Grove Eye Care PCs (SGEC) Notice of Privacy Policy and Practices (NPP). I am also aware a copy will be made available to me upon request. I authorize and consent to SGEC to use/disclose private health information about me according to the guidelines in its NPP. This includes any information required to file my insurance claim, carry out treatment, etc. I also authorize my insurance company to pay SGEC directly on my behalf and for said insurance company to provide any information required to resubmit any denied or incorrectly paid claims. This authorization remains in effect until withdrawn by me.

I understand I am responsible for any charges not covered by insurance.

______________________________________________________________ ____________________________

Signature of Patient/Parent/or Guardian Date signed