TODAY'S DATE

-- mm/dd/yy

CHOOSE ONE:         MR MRS MISS MASTER

LAST NAME:

FIRST NAME:

MIDDLE:

CHOOSE ONE:

MALE FEMALE

ADDRESS:

CITY:

STATE:

ZIP: 

HOME PHONE: 

WORK PHONE: 

CELL PHONE: 

   --mm/dd/yy

AGE:

SOCIAL SECURITY NUMBER:

EMAIL ADDRESS:

RESPONSIBLE PARTY (if different than above)

 RELATIONSHIP TO PATIENT

PHONE NUMBER:

ADDRESS

CITY:

STATE:

ZIP:

EMPLOYER NAME:

ADDRESS:

PRIMARY CARE PHYSICIAN:

PHONE NUMBER:

REFERRED BY:

PHYSICIAN FRIEND AD ER INSURANCE PLAN INTERNET OTHER

IF PHYSICIAN OR OPTOMETRIST, PLEASE GIVE NAME:

EMERGENCY CONTACT:

PHONE:

RELATIONSHIP TO PATIENT:

DOES YOUR PLAN REQUIRE REFERRALS FOR "SPECIALIST CARE

YES   NO

PRIMARY INS:

POLICY #

GROUP NAME

POLICY HOLDER

DOB 

-- mm/dd/yy

SECONDARY INS:

POLICY #

GROUP NAME

POLICY HOLDER

DOB 

-- mm/dd/yy

INSURANCE PAYMENT DISCLOSURE & SIGNATURE

I authorize Richard S. Casden, M.D., Betty Klein, M.D., and Hindola Konrad, M.D. to receive all insurance payments from my current medical insurance plan 

I agree to pay applicable co-payments, deductibles and non-covered fees.  I will pay my deductible and non-covered services upon first notification. 

I agree to pay applicable co-payments at the time of service. 

If my plan requires a prior approval or referral, I accept responsibility for all payments for non-approved and/or non-referred charges.  

I agree to release all information necessary for my current insurance plan to process my claims. 

I agree to pay in full at the time of service if I do not have insurance or choose not to have my insurance filed by your office. 

	I hereby acknowledge that I have read a copy of Acuity Eye Care’s “Notice of Privacy Practice.”  I understand that if I have any questions or complaints regarding my privacy rights that I may contact Suzanne Grazioli, Privacy Officer for Acuity Eye Care, at (203) 794-0117.  I further understand that the practice will offer me updates to this notice should the notice change in any way.