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Patient Information form

SECTION 1: PATIENT INFORMATION

All Fields with Asterisks are Requried

Last*

First*

Middle Initial*

Title*

Last four digits of SSN#*

Date of Birth*

Gender*

MaleFemale

Home Address*

City*

State*

Zip*

Home#*

Cell#*

Alternate#*

Email Address*

Please do not use my email for office communication (e.g., patient portal. Your email is never sold or used for other purposes.

Race*

Caucasian/WhiteAfrican AmericandAsianAmerican IndianHispanic/LatinoPacific IslanderOtherDecline to Answer

Ethnicity*

HispanicNon-Hispanic

Preffered language if not English*

SECTION 2: RESPONSIBLE PARTY/PARENT/GUARANTOR

for patients less than 18 years old

Relationship to Patient*

Self (skip this section)SpouseParent

Last*

First*

Middle Intial*

Title*

Gender*

MaleFemale

Home Address*

City*

State*

Zip*

Home#*

I authorize A+ Vision Optometry to treat/care for this child under the general supervision of any staff optometrist. This consent is given pursuant to the provisions of section 25.8 of the Civil Code of California.

Signature*

Date*

SECTION 3: EMERGENCY CONTACT INFORMATION

Last*

First*

Relationship to Patient*

Preferred Phone*

SECTION 4: PRIVACY RIGHTS ACKNOWLEDGEMENT*

I have read A+ Vision Optometry Privacy Notice and understand my rights contained therein. By way of my signature, I acknowledge that A+ Vision Optometry has provided me with a policy regarding the use and disclosure of my protected health care information for the purposes of treatment, payment, and health care operations as described in the Privacy Notice. A copy shall be as valid as the original.

Signature*

Date*

SECTION 5: INSURED INFORMATION*

Relationship to Patient*

Self (skip this section)SpouseParent

Last*

First*

Middle Intial*

Title*

Last four digits of SSN#*

Date of Birth*

Gender*

MaleFemale

SECTION 6: VISION INSURANCE INFORMATION

(VSP, Eyemed, MES) Present your insurance card(s) to a team member

Name of Insurance*

Member ID#*

SECTION 7: MEDICAL INSURANCE INFORMATION

(Anthem Blue Cross, Blue Shield, Medicare, and supplemental) We do not accept HMO’s, Cigna, Kaiser or Medi-Cal/Cal Optima. Present your insurance card(s) to the receptionist.

Name of Insurance*

Member ID#*

If the patient is covered by more than one plan, please use the below boxes to list plan(s) type.

Name of Insurance*

Member ID#*