Online Patient Registration Form Please enter today's date: Referred by a Doctor? Yes No Name of Referring Doctor Reason for visit: How did you hear about us? Yellow Pages Friend/Relative Other PERSONAL INFORMATION: Patient’s Name: Last First Middle Mailing Address: City: State: Zip Street Address (if different from mailing): Home Phone: Work Phone Date of Birth: Social Security #: Male Female Marital Status (circle) M D S W Age: Employer: Occupation: Are you student? Yes No Employer Address City: State: Zip INSURED INFORMATION / RESPONSIBLE PARTY FOR MINORS: Insured’s Name: Social Security #: Date of Birth Primary Insurance: Secondary Insurance: Employer: Work Phone: EMERGENCY INFORMATION: Name: Relationship: Emergency Phone: **Please be prepared to present drivers’ license and any insurance cards to receptionist.** **We will endeavor to make your visit both pleasant and thorough. Due to this your eye(s) may be dilated. Dilation may last from 12-72 hours.** **Please allow at least 1-2 hours for your first visit.** Authorization for Treatment / Release of Information and Assignment Insurance and Financial Policy The undersigned hereby authorizes Nini S. Patheja, M.D., Daniel J. Smith, M.D, and/or Jeffrey D. Kozlowski, O.D. to administer such treatment as is necessary on the basis of findings during the course of the examination. I authorize disclosure of portions of the patient’s record to the extent necessary to determine liability for payment and to obtain reimbursement. I hereby assign all benefits, to include major medical, Medicare, Medicaid, Private Insurance, Workers Compensation, to Nini S. Patheja, M.D., Daniel J. Smith, M.D. and/or Jeffrey D. Kozlowski, O.D. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for allcharges, whether or not paid by the insurance carrier.I also understand that it is the policy of Aiken Ophthalmology that any charges for services rendered by our physician and staff be paid for at the time of service.If credit arrangements are necessary, they must be made prior to services being rendered. I hereby authorize assignee to release all information necessary to secure payment. Patient / Guardian Signature Date
Please enter today's date: Referred by a Doctor? Yes No Name of Referring Doctor
Reason for visit: How did you hear about us? Yellow Pages Friend/Relative Other
PERSONAL INFORMATION:
Mailing Address: City: State: Zip
Street Address (if different from mailing):
Home Phone: Work Phone Date of Birth:
Social Security #: Male Female Marital Status (circle) M D S W Age:
Employer: Occupation: Are you student? Yes No
Employer Address City: State: Zip
INSURED INFORMATION / RESPONSIBLE PARTY FOR MINORS:
Insured’s Name: Social Security #: Date of Birth
Primary Insurance: Secondary Insurance:
Employer: Work Phone:
EMERGENCY INFORMATION:
Name: Relationship: Emergency Phone:
**Please be prepared to present drivers’ license and any insurance cards to receptionist.**
**We will endeavor to make your visit both pleasant and thorough. Due to this your eye(s) may be dilated. Dilation may last from 12-72 hours.**
**Please allow at least 1-2 hours for your first visit.**
Authorization for Treatment / Release of Information and Assignment Insurance and Financial Policy
The undersigned hereby authorizes Nini S. Patheja, M.D., Daniel J. Smith, M.D, and/or Jeffrey D. Kozlowski, O.D. to administer such treatment as is necessary on the basis of findings during the course of the examination. I authorize disclosure of portions of the patient’s record to the extent necessary to determine liability for payment and to obtain reimbursement. I hereby assign all benefits, to include major medical, Medicare, Medicaid, Private Insurance, Workers Compensation, to Nini S. Patheja, M.D., Daniel J. Smith, M.D. and/or Jeffrey D. Kozlowski, O.D. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for allcharges, whether or not paid by the insurance carrier.I also understand that it is the policy of Aiken Ophthalmology that any charges for services rendered by our physician and staff be paid for at the time of service.If credit arrangements are necessary, they must be made prior to services being rendered. I hereby authorize assignee to release all information necessary to secure payment.
