Patient Information Sheet

 2445 E. Wilcox Dr. - Sierra Vista, AZ 85635 - (520) 458-8131
4116 Avenida Cochise, Suite # A - Sierra Vista, AZ 85635 - (520) 452-1125
880 W. 4th St., Suite # 3 - Benson, AZ 85602 - (520) 586-7877
Last Name
____________________________		 First Name
 _______________________________		 Middle Name
__________________
Address
_________________________________		 City
__________________________		 State
 _______		 Zip
 _________
Social Security#
________________		 Home Phone#
_______________		 Work Phone#
______________		 Birthdate
______________		 Age
_______
Sex
____________		 Marital Status
________________		 Name of Family Doctor
________________________________________________

Insurance Names
Please List By Order

Policy Holder
Name

Relationship
To Patient
1._________________________ 1._____________________________ 1.___________________
2._________________________ 2._____________________________ 2.___________________
3._________________________ 3._____________________________ 3.___________________
Primary Insurance Holder
_________________________________________________		 Birthdate
____________		 Social Security#
_______________
Address
_________________________________________________		 Home Phone#
_____________		 Work Phone#
_______________
2cnd Insurance Holder
_________________________________________________		 Birthdate
_____________		 Social Security#
_______________
Address
_________________________________________________		 Home Phone#
_____________		 Work Phone#
_______________
Parent Information (if applies)
________________________________________________		 Parent Birthdate
_____________		 Parent SSN#
_______________
Address
_______________________________________________		 Home Phone#
______________		 Work Phone#
_______________
 
I request that payment under the medical insurance program be made directly to Cochise Eye & laser on any unpaid bills for services furnished me by Cochise Eye & Laser. I authorize the above named provider to release any information to insurance carriers needed for this claim. I further permit a copy of this authorization to be used in place of its original.

IT IS UNDERSTOOD, I AM RESPONSIBLE FOR ALL FINANCIAL OBLIGATIONS of health services, and for reimbursement and payment of claims from my insurance company. I understand that payment is expected at the time services are rendered unless other arrangements are made in advance. If for any reason the account should become delinquent, I agree to   pay for all rebilling charges, interest charges, collection costs and reasonable legal fees.

_______________________________________________
Patient or Responsible Party

_____________________
Date
 
If patient is under age 18, parents name:___________________________________. I hereby
give permission for the doctor/employees of Cochise Eye & Laser, to treat my child.


 

______________________________
Parent/Legal Guardian