New Patient Form 1PATIENT2GUARANTOR3EMERGENCY CONTACT4SIGNATURE ADULT NEW PATIENT FORMFirst NameLast NameDate of birthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Row 2 StartAddress Line 1Address Line 2Row 3 StartCityStateSELECTAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipRow 4 NewHome phoneWork phoneMobile phonePreferred LanguageRow 5 NewRace White Black or African American American Indian or Alaskan Native Asian Caucasian Naive Hawaiian or Other Pacific Islander Other Decline to specify Row 5-A NEW INSERTEthnicity Unknown/Not reported Not Hispanic or Latino Hispanic or Latino Decline to specify Row 5-C NEW INSERTGender Male Female Row 6 StartEmail Row 7 NewPharmacy NamePharmacy PhoneRow 8 NewInsurance TypeInsurance ID Page 2 Row 1 NEWPolicy holder's name as listed on cardDate of BirthMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Page 2 Row 2 NEWRelationship to person responsible for payment Self Spouse Child Other Page 2 Row 3-INSERT NEWGuarantor first nameGuarantor last namePage 2 Row 3 NEWGuarantor Address line 1Guarantor Address line 2Page 2 Row 4 NewGuarantor CityGuarantor StateSelectArmed Forces AmericasArmed Forces Europe: Middle East, & CanadaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificGuarantor ZipPage 2 Row 5 NEWGuarantor Home PhoneGuarantor Work Phone Page 3 Row 1 NEWEmergency contact first nameEmergency contact last namePage 3 Row 2 NEWEmergency contact work phoneEmergency contact home phoneEmergency contact mobile phone Page 4 Row 1 NEWPrimary care physician's namePage 4 Row 2 NEWSubmitting this form authorizes us to release information and receive payment from your insurance company. This Authorization Remains in Effect Unless Revoked by me in Writing: I hereby authorizePremier Ophthalmology, LLC hereinafter referred to as “Provider”, to provide information concerning any treatment rendered to me to: a) my insurance carrier(s); b) my primary care physician c) any medical practitioner “Provider” may refer me to for further medical or therapy treatment. I authorize as necessary to process insurance claims or required for utilization review or quality assurance activities, the release of any medical information,including confidential information related to psychiatric care, drug, and alcohol abuse, and HIV / AIDS treatments. I hereby assign to“Provider” all applicable payments to be received from my insurance carrier(s) for medical services rendered. I understand that any remaining credit balance shall be refunded directly to me. I hereby agree thatI am personally responsible for ensuring that all charges for services rendered are paid by either myself or my insurance carrier(s) I further authorize “Provider” to utilize any modern form of transferring this documentation – including, but not limited to, the US Mail, Federal Express, telefacsimile (faxes), couriers or other similar methods – to its requested destination. Δ
