Tricare Patient Information Sheet
 You can fill this out online with this form and a copy will be sent to your email. You can then print the copy, sign it and bring it in with you on your visit. You can also get the printable version HERE and print the form out and fill it in to bring with you on your visit.

Printable Version
 		 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#
 _____________		 Business Phone#
_______________		 Birthdate
 __________		 Age
____
Sex(circle one)
        M   F		 Marital Status(circle one)
Single Married Divorced
Separated Widowed		 Name of Referring Doctor or Patient
 ______________________________________
Responsible Party For Billing(circle one) Self Spouse Parent W/Comp
Insurance Company
1._______________________		 Group#
 ___________		 Policy#
___________		 Subscriber
 ______________		 Relationship
 ______________
2._______________________ ___________ ___________ ______________ ______________
Responsible Party: __________________________________ DOB: ____________
Occupation:
 __________________________		 Business Address:
 ______________________________________________________
Business Phone#
  		 _____________________
  
Spouse's Name:
 _____________________________________________		 Occupation:
 __________________________________
Business Address:
 ____________________________________________________________		 Business Phone#
 __________________
Name of Family Doctor or Internist: _________________________________________________
 
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.

_______________________________________________
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