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Online Registration Form


PATIENT INFORMATION: Please Print Date:

Patient Name: (Dr. Mr. Mrs. Ms. Rank )  

Street Address:                                                                                              email address:

City, State, Zip: 

Home Phone: Business Phone: Sex:    Marital Status: M S W

Age:      Patient Social Security #       Date of Birth:

Patient Employed by:

How did you learn about our office?

When was your last physical exam? Family Physician:

Spouse Name:   Business Phone:

Nearest Relative or Friend not living with you (In case of emergency): Name:

Relationship:    Address:

Phone: Home Work


INSURANCE INFORMATION:

Policy Holder’s Name:

Primary Insurance:

Effective Date:

Other Insurance: 

Effective Date:

Planned Method of Payment:


AUTHORIZATION:
I understand that I am responsible for all charges for services provided by San Antonio Eye Center and/or the San Antonio Eye Surgicenter. I understand that a collection fee will be charged for accounts that require collection procedures. 

I authorize release of any medical information necessary to process my insurance claims and request payment of insurance benefits to either myself or the party who accepts assignments/participation with my insurance company.

Date Signature of Patient or Legal Guardian:

By typing my name and date I agree to the authorization.

MEDICARE LONG-TERM AUTHORIZATION:
I request that payment of authorized Medicare benefits be made either San Antonio Eye Center, P.A, or any of its associates, or San Antonio Eye Surgicenter for any service furnished me by San Antonio Eye Center (Dudley H. Harris, M.D., P.A.).  I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the benefits payable for related services.

Date Signature of Patient or Legal Guardian:

By typing my name and date I agree to the authorization.
MEDIGAP AUTHORIZATION:

I request that payment of authorized Medigap benefits be made on my behalf to San Antonio Eye Center, P.A, any of its associates or San Antonio Eye Surgicenter for any service furnished me. 


I authorize any holder of medical information about me to release toany information needed to determine these benefits or benefits payable for related services.
  
(Name of Medigap Insurance)

Date Signature of Patient or Legal Guardian:

          By typing my name and date I agree to the authorization.
(210) 226-6169
Copyright 2011: San Antonio Eye Center, P.A. Eye Doctor San Antonio. All Rights Reserved.
800 McCullough, San Antonio, TX 78215 | (210) 226-6169