Patient Financial Information Sheet in New Ulm, MN | Dr. Akre and Clark Family Eye Health Center

Company

This field is for validation purposes and should be left unchanged.

Assignment of Benefits

I understand that payment in full is due at time of service unless other arrangements have been made.

First Name*

Middle Name

Last Name*

Preferred Name

Date of Birth*

Home Phone

Cell Phone

Marital Status*

Primary Insurance Company

Name of Policy Holder*

Policy Holder Date of Birth*

Employer*

File

Max. file size: 256 MB.

Date of Birth*

First Name*

Last Name*

Responsible Party

Secondary Insurance Company

Policy Holder Date of Birth

Name of Policy Holder

Employer

Responsible Party

Date of Birth*

First Name*

Last Name*

Authorization and Release

I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third party payers and/or other health practitioners. I authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me. I understand that my insurance carrier may not cover all or may pay less than the actual bill for services that I received. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I authorize the release of medical information including the diagnosis, treatments and financial information rendered to me and/or my child to the following individuals…

List name(s)*

Signature of Patient / Parent if a minor*

This authorization expires 10 years from signature date.

Date*

HIPAA Privacy Practice Acknowledgment

NOTICE OF PRIVACY PRACTICES

Signature*

I have received or was offered and declined a notice of privacy practices.

Date*

Upload a photo of your insurance card

Max. file size: 256 MB.

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Patient Financial Information Sheet