Advanced Vision Institute

PATIENT INFORMATION

First Name:	MI	Last Name:	DOB

Address:	City:	State:	Zip:

Note: If you would like to receive appointment reminders via text, please check the appropriate box.

OK TO TEXT OK TO E-MAIL

HOME#	CELL#	WORK#
E-MAIL:	SSN#	MARITAL STATUS:
EMPLOYER:	OCCUPATION:

WHOM MAY WE THANK FOR REFERRING YOU?

WHO IS YOUR OPTOMETRIST?

INSURANCE INFORMATION (List the subscriber information if different than above)

PRIMARY INSURANCE:		SECONDARY INSURANCE
SUBSCRIBER NAME:		SUBSCRIBER NAME:
SSN:		SSN:
DOB:		DOB:

DEMOGRAPHIC INFORMATION

ETHNICITY: Hispanic or Latino Not Hispanic or Latino

GENDER: Male Female

RACE:

American Indian or Alaska Native
Asian __Black or African American
Native Hawaiian or Other Pacific Islander
White
Other

PATIENT RELEASE FORM

The doctors/staff of Advanced Vision Institute may release my medical information or answer questions about my care, either verbally or in writing, to the following: (Please initial each appropriate answer and complete)

Myself/Patient (Required in case you call our office requesting record or to verify /change appointments)

Family Member (s)–Name (s)

Optometrist/Primary Care Doctor

EMERGENCY CONTACT/PHONE #:

Please understand: Due to HIPAA regulations, without your consent, we cannot discuss
anything about you with anyone, including confirming appointment times.
Authorization to Release and Assign Insurance Benefits: I understand that I am financially responsible to said doctor for charges. In the case of default on payment of this account, I agree to pay all collection costs, attorney fees, and court costs incurred in attempting to collect on the outstanding balance.
Office Financial Policies: Payment is expected at the time of service. This includes all co-pays, deductibles and outstanding balances. For your convenience, we offer the following methods of payments: CASH CHECK MASTERCARD VISA DISCOVER AMERICAN EXPRESS
***There is a $35.00 fee for a check returned by the bank for any reason***
Missed Appointment Policy: If you cancel your appointment without 48 hours notice or do not keep your appointment you will be charged a $50.00 No Show Fee. If you cancel a surgery appointment, to include cataract surgery, any laser procedure or in-office procedure, without 48 hours notice, or fail to keep your appointment, or have your surgery cancelled as a result of eating or drinking prior to your procedure, you will be charged a $100.00 No Show Fee.
Your signature below signifies your understanding, acceptance and agreement to our office policies.

Responsible Party Signature	Date

REV 5/2013