SILVERMAN EYECARE Bonnie S. Silverman, M.D. P.C.
PATIENT INFORMATION ∗ NAME AS IT APPEARS ON YOUR INSURANCE CARD
LAST NAME__________________________ FIRST NAME_________________________MI_________ ADDRESS__________________________ CITY___________________ STATE________ ZIP________ HOME PHONE_________________ WORK PHONE________________ CELL PHONE_____________ (Please circle best contact phone #) D.O.B_______/_______/_______
GENDER: MALE FEMALE
D S W
SOCIAL SECURITY (FOR INS PURPOSES ONLY) ______________-______________-_____________ EMPLOYER: _________________________________________________________________________ EMERGENCY CONTACT_________________________________ PHONE #_____________________ EMAIL ADDRESS: ________________________________________________@__________________
INSURANCE INFORMATION PRIMARY INSURANCE _________________________________ ID# ___________________________ POLICY HOLDER _____________________________________ D.O.B. ________________________ RELATIONSHIP TO PATIENT:
SECONDARY INSURANCE ______________________________ ID# ___________________________ REFERRING DR. ________________________________ PHONE # ____________________________ FAMILY DR NAME/ ADDRESS __________________________________________________________ I hereby authorize Bonnie S. Silverman, M.D. P.C. & staff to release any of my medical information to facilitate insurance claims processing. I authorize payment for services rendered by my insurance company to be sent directly to Bonnie S. Silverman, M.D. P.C. In addition, I authorize disclosure of my medical information to another physician by Dr. Silverman when required as consultation or to coordinate my care. I agree to provide Dr. Silverman?s office with: * Accurate and prompt information concerning my health insurance plan. * Prompt notification, if any changes in my insurance plan or coverage occur during my course of treatment with Dr. Silverman. I understand that I am financially responsible for ANY services, which are not covered by my insurance plan. (including, but not limited to, refraction examinations (exam by Dr. Silverman to determine if a prescription for eyeglasses may be necessary) I also acknowledge that I will be financially responsible, in accordance with my subscriber contract and Dr. Silverman’s plan participation contract: * If my insurance plan denies payment because I fail to comply with its procedures, or * If I provide incorrect information which causes a delay in submitting the claim, or * If I fail to bring any referral forms or other documents which my insurance plan requires. * Any deductible and coinsurance amounts per my plan participation contract * I am aware that Dr. Silverman DOES NOT participate directly with THE EMPIRE PLAN (government employee)- claims sent on my behalf may result in an out-of pocket expense to me.
PLEASE NOTE: All missed appointments without 24 hours prior notification will be charged a $25.00 fee
Patients Signature ________________________________ Date ________________________
Published on Mar 4, 2011
SECONDARY INSURANCE ______________________________ ID# ___________________________ LAST NAME__________________________ FIRST NAME___________...