TFE PATIENT INFORMATION .pdf

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Original filename: TFE_PATIENT_INFORMATION.pdf
Title: PATIENT INFORMATION
Author: .

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PATIENT INFORMATION
Date: _____________________________
Patients Name: ______________________
(last name)
Birthdate: ______________________

_____________________________
(first name)

M or F

Marital Status:

M D S W

Address: ____________________________________________________
____________________________________________________
Phone number: ___________________________ Cell: _____________________
E-Mail: _________________________________
How / Whom referred you to our office?
_______________________________________________________________

Name of Insurance: ______________________________________
Primary Holders Name: _______________________________________________
Insurance ID# ________________________________ Group# ________________
SSN#: _______________________ DOB: _____________________________
(primary holders)
Address: _________________________________________________________
_________________________________________________________
The fee for service is an obligation of the patient and is due at the time of service. If you
have medical insurance, we will assist in obtaining full allowable benefits. But in the event
the insurance company refuses previously confirmed coverage or reimburses a lesser
amount than charged, the patient is fully responsible for the entire obligation. Any service
not covered by your insurance company must be paid at the time of service.
I fully understand that I am directly and fully responsible to Total Family Eyecare for all
medical bills submitted by TFC, or its agents, for services rendered to me.

Authorized Signature: _____________________________
Print Name: __________________________________


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