PATIENT INFORMATION FORM
* Required fields.
*Name: (Last) *(First) (MI)
Address City State Zip
Date of Birth Sex M F Age Social Security #
Home Phone# Business Phone# Cellular #
Employer Occupation
Address City State Zip
E-mail Address Referred by
In case of emergency contact: Phone#
Marital Status : S M D W   Family Doctor:

Spousal/Parent Information :
Name Date of Birth SSN #
Address if different from patient :
parent_employer
Employer Occupation
Address City State Zip
Primary Insurance : Who is the policy holder self / spouse
Name of Insurance ID# Group#
Insurance Address
Subscriber's Name Relationship DOB
Address if different from patient :
Do you have vision coverage through your medical insurance: Yes / No
Secondary Insurance
Is patient covered by additional Insurance ? Yes / No Name of Insurance
Insurance Address ID# Group#
Subscriber's Name Relationship DOB
Address if different from patient :
 

I, the undersigned, certify that I (or my dependent) have insurance coverage with the above mentioned companies and assign directly to ReVision all insurance benefits, if any, otherwise payable to me for services rendered. I authorize use of my signature on all insurance submissions. I acknowledge that I am financially responsible for all unpaid debt as a result of services performed at this facility, as well as payment for procedures that my policy will not cover, including a refraction for $47.00 that most insurance company’s do not cover. To the extent necessary to determine liability for payment, and to obtain reimbursement, I authorize disclosure of portions of my medical records.

Please note that each patient is responsible to check with their insurance to insure that the doctor you are seeing is covered by your specific policy.

 
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