Medical And Vision Insurance Information Form printable pdf download

New / Update

_____/ M / F / J / K

: (First) _______________________ (MI) ___________ (Last) ___________________________

PATIENT NAME

: __ Single __ Married __ Divorced __ Widowed __ Separated

: Male Female

MARITAL STATUS

SEX

: _________________

: _______

: _________________________

: ___ Full ___ PT

DOB

AGE

SSN

STUDENT STATUS

ADDRESS

: ___________________________________

_______________________

_____

____________

MAILING

CITY

STATE

ZIP

: _________________________________________

_______________________

_______

__________

PHYSICAL

CITY

STATE

ZIP

(____) _______--_________

(____) ______--_________

_______________________

(____) _______--________

CELL

EMPLOYER

: ________________

: ________________________

: (___) ______-_________

SPOUSE’S NAME

EMPLOYER

WORK #

**Name of nearest relative or friend not living with you: ___________________________ Phone: (____) _______-_______

**My Family Doctor: ___________________________

** I was referred by: ____________________________

MEDICAL AND VISION INSURANCE INFORMATION

♦Are you currently being followed by Hospice Care?

♦Is this visit Worker’s Compensation?

Y N

♦Will this visit be Self-pay/No Insurance? Y

♦Do you have prescription drug coverage? Y N

__________________

Spectera #: __________________ ECPA (EyeMed) #: __________________ Southland #: _______________

Primary Ins: ______________________ Contract #: ______________________________ Group #: ______________

Secondary Ins: _____________________ Contract #: _____________________________ Group #: ______________

Tertiary Ins: ______________________ Contract #: _____________________________ Group #: ______________

FINANCIAL AGREEMENT / ASSIGNMENT OF BENEFITS

(___) _____-________

(___) _____-__________

Responsible Party _________________________

HM #

WK/CELL #

_________________________________

__________________

______

_________ (

ADDRESS

CITY

STATE

ZIP

INDIVIDUAL not an ins. co.)

MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to TUSCALOOSA OPHTHALMOLOGY, P.C. for services furnished

me by TUSCALOOSA OPHTHALMOLOGY, P.C. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid

Services (formerly Health Care Financing Administration) and its agents any information needed to determine these benefits or the benefits payable for related

services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance

is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the Insurer or agency

shown. TUSCALOOSA OPHTHALMOLOGY, P.C. accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the

deductible, coinsurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier.

MEDIGAP: I understand that if a MediGap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim

forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made

on my behalf to TUSCALOOSA OPHTHALMOLOGY, P.C. if possible or otherwise to me.

OTHER INSURANCE: I understand that TUSCALOOSA OPHTHALMOLOGY, P.C. maintains a list of health care service plans with which it contracts. A list of

such plans is available from the business office. And that TUSCALOOSA OPHTHALMOLOGY, P.C. has no contract, expressed or implied, with any plan that does

not appear on the list. The undersigned agrees that I am individually obligated to pay the full charges of all services rendered to me by TUSCALOOSA

OPHTHALMOLOGY, P.C. if I belong to a plan that does not appear on the aforementioned list.

NON-COVERED SERVICES: I understand that TUSCALOOSA OPHTHALMOLOGY, P.C.’s contracts with health care service plans (i.e. HMOs, PPOs) relate

only to items and services which are “covered” by the health care service plans. Accordingly, the undersigned accepts full financial responsibility for all items or

services, which are determined by the health care service plans not to be covered. Examples of non-covered services include, but are not limited to, services not

specified as being covered in the patient’s contract with a health care service plan or in the benefit summary the health care plan furnishes to the patient; and

treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with TUSCALOOSA OPHTHALMOLOGY, P.C. to obtain

necessary health care service plan authorizations.

I agree that in return for the services provided to the patient by TUSCALOOSA OPHTHALMOLOGY, P.C., I will pay my account at the time service is rendered or

will make financial arrangements satisfactory to TUSCALOOSA OPHTHALMOLOGY, P.C. for payment. If an account is sent to an attorney for collection, I agree to

pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that is my account is

delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the

patient, is hereby assigned to TUSCALOOSA OPHTHALMOLOGY, P.C. If my insurance company or health plan designates copayments and/or deductibles, I agree to

pay them to TUSCALOOSA OPTHALMOLOGY, P.C. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of

my bill.

Authorized Signature: ________________________________________ Date: _____________________

Medical And Vision Insurance Information Form

Related Articles

Related forms

Related Categories