Medical History Registration

STEP 2: INSURANCE INFORMATION

Who is responsible for this account?
Relationship to patient (if not self)
Insurance Company
Group #:
Birthday:
Social Security #:

Is patient covered by additional/secondary insurance?: Yes No

Policyholder Name
Relationship to patient (if not self)
Insurance Company
Group #:
Birthday:
Social Security #:

ASSIGNMENT & RELEASE / MEDICARE AUTHORIZATION

I, the undersigned, certify that I or my dependant have insurance coverage with , and assign directly to The Bond- Wroten Eye Clinic ("The Clinic") all insurance benefits, if any, otherwise payable to me for services rendered. I understand I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure payment of benefits. I authorize use of this signature on all insurance submissions. I also certify that all medical information provided on this form is true and accurate to the best of my knowledge.

If applicable, I request payment of authorized Medicare benefits be made on my behalf to The Clinic for services furnished to me by The Clinic. I authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services and its agents any information needed to determine those 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 CMS-1500 form, or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge. Coinsurance and deductibles are based upon the charge determination of the Medicare carrier.

By checking here I agree to the above terms:

STEP 3: MEDICAL HISTORY QUESTIONNAIRE

PAST PERSONAL HISTORY

MEDICATIONS

[MU]

Describe all serious illnesses, and surgeries:

PRIMARY CARE PHYSICIAN:	Phone #:	Fax #:

Address:

IN CASE OF EMERGENCY, CONTACT:

Name:	Relationship:
Phone #:Home:	Work:
		Doctor"s Initials: