Patient Information Form

(Please print off the following 2 page form, complete, and bring to your appointment.)

Name________________________________________ Date ____________

Age___________ Date of Birth________________________

Address___________________________________________________________

City__________________________ State___________ Zip Code_____________

Marital Status ______________ SS# _____ - _____ - ______

Occupation ____________________ Employer____________________________

Phone - Home ___________________ Work_____________________

Who were you referred by?_________________________________________

General Medical Doctor (full name)_________________________________________

Are you responsible for payment of your bills? Yes______ No______

If not, who is responsible?(name)_________________________________________

What is their relationship to you?_________________________________________

Address____________________________ City_______________ State/ Zip___________

*If student, list parent or guardian________________________________________

Nearest relative_______________________________ Phone#_________________

Do you have any of the following insurances?

______ Medicare Part B
______ Patient's Choice
______ Erisco
______ Workers Comp
______ Travelers Health Network
 ______ POMCO
______ PHP
______ IPHP
______ GHI
 ______ Blue Shield
______ Empire Plan
______ RMSCO
Other____________
Insurance Company Address___________________________________________________

Is this visit covered by No-Fault Auto Insurance? Yes _____ No______

Name of No-Fault Carrier____________________________________________________


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Medicare Benefits
   I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical information about me to be released to the Social Security Administration, or it's carriers, any information required to process my Medicare claim.

      Signature_____________________________________________


Commerical Insurance
   I hereby authorize the Syracuse Eye Center to release medical information necessary for filing claims for services rendered to the insurance companies listed above.

      Signature_____________________________________________

Syracuse Eye Center
612 University Avenue
Syracuse, NY 13210
Tel: (315) 422-2020      Fax: (315) 422-7339
E-mail: mail@syreyectr.com

Copyright Syracuse Eye Center 1999