Patient Information Form - Family Eye Care

Patient Information

Name(Required)

First Middle Last

Physical Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Mailing Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Date of Birth(Required)

Age(Required)

Male

Female

Identify As

SS#(Required)

Language(Required)

Race

Marital Status

Married

Widowed

Single

Divorced

Home Phone(Required)

Cell Phone(Required)

Text Reminders(Required)

Yes

E-mail Address

E-mail Reminders(Required)

Yes

Employer(Required)

Occupation(Required)

Work Phone(Required)

Work Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Employment Status(Required)

Is patient currently under hospice care?(Required)

Yes

Parent/Guardian Information (Authorized Representative)

Name

First Last

Relationship to Patient

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Employer

Date of Birth

Insurance Information Subscriber Other Than Patient

Subscriber Name(Required)

Subscriber Employer(Required)

Subscriber DOB(Required)

Relationship(Required)

Primary Medical Insurance(Required)

Primary Medical Insurance Address(Required)

Primary Medical Insurance Policy #(Required)

Primary Medical Insurance Group #(Required)

Secondary Medical Insurance(Required)

Secondary Medical Insurance Address(Required)

Secondary Medical Insurance Policy #(Required)

Secondary Medical Insurance Group #(Required)

Vision Insurance(Required)

Vision Insurance Address(Required)

Vision Insurance Policy #(Required)

Vision Insurance Group #(Required)

Emergency Contact

Name(Required)

Relationship to Patient(Required)

Phone #(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code

NOTE: Most insurance policies pay only a portion of your total charges. If you have any questions about your coverage, please contact your representative. We do not guarantee the accuracy of benefit information given to us by insurance companies. Please understand that financial responsibility for your account is yours, not the responsibility of your insurance company. I authorize the release of any medical or other information necessary to process insurance claims. I authorize payment of medical or vision benefits either to the physician or supplier of the service rendered or to myself if the provider does not accept assignment. I understand that I am responsible for any balance my insurance does not pay.

Initials(Required)

Payment is Expected on Date of Service(Required)

Cash

Check

Credit Card

FECC Vision Direct

(i.e., CO-PAYS, DEDUCTIBLES, CO-INSURANCE, GLASSES, CONTACT LENSES, ETC.)

Signature(Required)

Date(Required)