BEFORE & AFTER
Patient Registration Form:
Indicates required field
Maiden Name/ Also Known As (AKA):
Preferred Phone #
American Indian or Alaska Native
Black or African American
Native Hawaiian/ Pacific Islander
Do you have a Primary Care or Family Physician (PCP)?
PCP City, State
PCP Phone Number
How did you hear about our office
My Physican/Doctor's office
Walk In/ Drive by
Name of referring doctor or hospital (if applicable)
Consent to treatment and release of information:
Unless otherwise directed below, if I am unavailable, the Physician may communicate normal test results via telephone, voicemail, or answering machine to the phone numbers on this form, as long as the nature of the call is not disclosed.
In addition, my normal test result may be communicated to (name and relationship):
No, I want my test results only communicated personally to me. If so, initial here:
I authorize examination and medical treatment, verification of benefits and the release of information (including the diagnosis and medical records) to other physicians involved in my care, to my insurance company to facilitate billing and reimbursement, and for quality assurance purposes. I acknowledge that I have been offered and received or declined to receive a copy of the HIPAA Notice of Privacy Practices. I authorize benefits to be paid directly to the Physician and I understand that I am responsible for any unpaid balance under the terms of my insurance policy. Patient/Legal Guardian Signature
please type or electronically sign
Print Patient/ Legal Guardian Name
Visit With Us Soon!
M-F: 8am - 4pm
© 2020 Illinois Oculoplastic Associates, S.C. All Rights Reserved.