Lasik

Cateract Surgery

Macular Degeneration

Glaucoma

Pediatric Eye Care

Retina








Patient Information
* REQUIRED
Patient Name:*
Social Security:*
Home Phone:*
Work Phone:
Address:*
City:*
State:*
Zip:*
Date Of Birth:*
/ /
ex:01/02/1965		 Sex:*
Male Female
Marital Status:*
Married Single Widowed Divorced
Additional Patient Information
Alternate Phone:
Cell Phone:
Pager:
Fax:
Email:
 
Emergency Contact
Name:*
Phone:*
Insurance Information*
Primary Insurance:
ID:
Insurance Address:
Date Of Birth:
/ /
ex:01/02/1965
Zip:
State:
Self Pay
Policy Holder General Information
Policy Holder Name:
Policy Holder Social Security:
Policy Holder Phone:
Policy Holder Work Phone:
Policy Holder Address:
Policy Holder Employer:
Policy Holder Relation To Patient:
 Policy Holder Date Of Birth:
- -
ex:01/02/1965
Second Insurance Information
Insurance:
ID:
Name Of Policy Holder:
Policy Holder Date Of Birth:
- -
ex:01/02/1965
Policy Holder Social Security:
Policy Holder Phone:
Medical Information
Pharmacy Number:
Primary Doctor:
Doctor Phone:
 
Nature Of Complaint:
Accident Related:?
yes no		 Work Related:?
yes no
Explain How Injury Occured:
Appointment Request
1st Requested Date:
/ /
ex:01/02/1965 		2nd Requested Date:
/ /
ex:01/02/1965
Reason For Requesting Appointment:
PATIENT IS RESPONSIBLE FOR OBTAINING ALL REFERRALS*
I HEREBY AUTHORIZE ASSIGNMENT OF BENEFITS TO BE PAID DIRECTLY TO DOCTORS; NATTIS, NUDELMAN, MARCUS, HSU, LAMONICA, GROSS, SALZMAN. THIS ASSIGNMENT WILL REMAIN IN EFFECT UNTILL REVOKED BY ME IN WRITING. A PHOTOCOPY OF THIS AGREEMENT IS TO BE CONSIDERED VALID AS AN ORIGINAL. THE PATIENT IS RESPONSIBLE FOR ALL FEES REGARDLESS OF INSURANCE COVERAGE. IT IS ALSO CUSTOMARY TO PAY FOR SERVICE WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE. I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT IN FULL FOR ALL COINSURANCE AND DEDUCTIBLE COSTS, AS WELL AS ANY DOCTOR’S SERVICES WHICH ARE DETERMINED TO BE NON-COVERED OR DENIED. I AUTHORIZE MY PHYSICIAN TO RELEASE ANY MEDICAL INFORMATION NECESSARY TO PROCESS MY BILL.

info@lindyeye.com © 2004 Lindenhurst Eye Physicians & Surgeons, P.C., All Rights Reserved

Website Design, Development and Hosting