patient-registration - Wright Eye Care Center

Date

Gender

Age

Last Name:

Birthdate:

First Name/MI:

Marital Status:MarriedSingleWidowedMinor

Title: MissMrsMr.Dr.

Employment Status:

Address

Employer: (Parents Employer)

City:

Occupation:

State:

Zip:

Referred by:

Home Ph#

Cell #

Email:

INSURANCE POLICIES

Vision insurance is used for routine eye exams for glasses or contact lenses and includes VSP, Superior Eyemed, and Spectera. However, it does not cover medically related findings or complaints.
Medical insurance will cover medical findings or complaints such as dryness, redness, itch, burn, eye pain, floaters, headaches, glaucoma, cataracts,
macular degeneration and more.

Vision Insurance:

ID#

Group#

Primary Medical Insurance:

ID#

Group#

Secondary Medical Insurance:

ID#

Group#

GUARANTOR (POLICY HOLDER)

(If you are the patient and the Primary on the insurance you do not need to complete this portion.)
Medical insurance will cover medical findings or complaints such as dryness, redness, itch, burn, eye pain, floaters, headaches, glaucoma, cataracts,
macular degeneration and more.

Last Name:

First Name/MI:

Suffix:

Gender:

DOB:

SSN:

Address:

Home Phone:

City:

Cell Phone:

State:

Zip:

Employer:

ASSIGNMENT OF BENEFITS AUTHORIZATION

I authorize the doctor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the eye doctor or ophthalmic group insurance benefits otherwise payable to me - I understand that my eyecare insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf and that of my dependents.

CONSENT FOR TREATMENT

I hereby authorize Wright Eye Care Center to examine and treat me, or, the individual for whom I am responsible. During the course of exam, dilation drops may be used to dilate the pupils. These drops may cause temporary blurred vision and glare