Insurance Form Download Printable Version "*" indicates required fields Patient Name* First Last Date of Birth* MM slash DD slash YYYY Vision InsurancePolicy Holder (Vision Insurance)* Self Other Policy Holder Name (if not patient)*Relationship to Patient Self Spouse Parent Legal Guardian Partner Other If other, please specify*Name of EmployerWork PhoneAddress of EmployerPolicy Holder Date of Birth MM slash DD slash YYYY Insurance CompanyInsurance Group #Insurance Plan #Effective Date MM slash DD slash YYYY Medical InsurancePolicy Holder (Medical Insurance)* Self Other Policy Holder Name (if not patient)*Relationship to Patient Self Spouse Parent Legal Guardian Partner Other If other, please specify*Name of EmployerWork PhoneAddress of EmployerPolicy Holder Date of Birth MM slash DD slash YYYY Insurance CompanyInsurance Group #UntitledInsurance Plan #Effective Date MM slash DD slash YYYY If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.I give my consent for examination and treatment.*Please initial in the field below.I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.*Please initial in the field below.This information may be released to Spouse Family Friend Other Treating Physician(s) Do Not Release my Medical Information Signature NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.Consent I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Name of Patient/Legal Guardian*Signature of Patient/Legal Guardian*Date* MM slash DD slash YYYY All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. For security purposes, please enter 728 in the field below.*CAPTCHA