PATIENT INFORMATION FORM
(Please circle one: Mr. Mrs. Ms Miss M.D. D.D.S. Ph.D. D.O.)
Home Phone #:___________________________Work Phone #:________________________
or "Summer" Address:___________________________________________________
Gender: Male Female Marital Status:___________________________
Name of Spouse:______________________
State:__________ZIP Code:______________Phone #:________________________________
In Case of an Emergency, we may contact:
Referred to our office by:_______________________________________________________
Insurance Carrier (If applicable):________________________________________________
***Please present all insurance cards to the front desk***
Please check with the front desk to make sure we participate in your insurance plan. Failure to do so may result in a denial from your carrier or payment out-of-pocket.
I hereby authorize Brems Eye Center to furnish information to insurance carriers concerning my illness and treatment, and I hereby assign to the physician all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by insurance. I further permit a copy of this authorization to be used in place of the original.
***If you have a secondary insurance, we need a second signature, giving us permission to submit your charges and diagnosis to your secondary insurance as well. Please sign below.***