CochiseEye.com - Tricare Patient Information Sheet


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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

Marital Status

Name of Referring Doctor or Patient

Responsible Party For Billing:

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.

Your Email:

______________________________
Parent/Legal Guardian