Warwar Eye Group - Patient Registration Form

Please complete the information below and submit the form online, or if you prefer, print out the completed form and bring it with you when you come to our office.

PATIENT REGISTRATION

Date:

Patient Name:

Sex: M F

Street Address:

City, State, Zip:

Date of Birth:

Phone No.

Marital Status:

Single Married Widowed

Email Address:

Referring Doctor:

Address of Referring Doctor:

Social Security Number:

Spouse or Nearest Relative:

Phone No:

Relationship:

Person Responsible for Bill:

Address:

Employer:

Phone No:

INSURANCE INFORMATION

Primary Insurance Company:

Policy Holder:

Date of Birth:

Relationship to Patient:

SSN:

Mail Claims To: (Address)

Phone No:

Policy No:

Secondary Insurance Company:

Policy Holder:

Date of Birth:

Relationship to Patient:

SSN:

Mail Claims To: (Address)

Phone No:

Policy No:

Third Insurance Company:

Policy Holder:

Date of Birth:

Relationship to Patient:

SSN:

Mail Claims To: (Address)

Phone No:

Policy No:

IS THIS AN INDUSTRIAL INJURY CLAIM? The following information is required in order to process paperwork correctly. If you do not have this information at present, please contact us as soon as you receive it. Thank you.

Workers Compensation No.

Date of Injury:

Employer at Time of Injury:

Address:

PLEASE READ AND INDICATE YOUR AGREEMENT: PATIENT'S AUTHORIZATION TO RELEASE MEDICAL INFORMATION AND CLAIM PAYMENT AUTHORIZATION

By checking the box to the left and submitting this form, I hereby authorize the above physician(s) to release any information regarding services rendered by him and allow a photocopy of my signature to be used to file insurance, and grant permission for publication or presentation of my medical information or photographs for scientific/educational purposes only.

I hereby authorize and direct my insurer to issue payment check(s) for benefit payments due me for services rendered by the above named physician(s) to be made directly to him. Regardless of my insurance benefits, if any, I understand I am financially responsible for the fees for services rendered.

If printing form, please date and sign:

Date:________________

Sign Here:_________________________________________________
Responsible Party, Policy Owner,
Insured Patient (or Parent or Guardian if minor)

MEDICARE PATIENTS ONLY - COMPLETE THIS SECTION
STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDER, PHYSICIAN AND PATIENT

By checking the box to the left and submitting this form, I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize my holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request the payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the service or authorize such physician or organization to submit a claim to Medicare for payment for me.

I request that payment under the medical insurance program be made either to me or the above named physician(s).

If printing form, please date and sign:

Date:________________

Signature:_________________________________________________

AUTHORIZATION FOR RELEASE OF INFORMATION

By checking the box to the left and submitting this form, I hereby authorize Palmetto GBA to furnish to the above named physician any information regarding my Medicare claims under Title XVIII of the Social Security Act. I understand that this release will be valid one year from the date of submission of the form or the date written below if printed, unless I send a written notice to the above Company that the authorization is to be withdrawn at an earlier date.

If printing form, please date and sign:

Date:________________

Signature:_________________________________________________

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