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Patient Information form

SECTION 1: PATIENT INFORMATION

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#