Patient Registration Form Patient Registration Form Step 1 of 3 33% Preferred Location*Yakima officeBellevue officeName* First Name M.I. Last Name Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhonePreferred Method of Contact*HomeCellWorkEmail* Family Physician or Pediatrician*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex*MaleFemaleMarital Status*Social Security Number*Employer Name*Emergency Contact Name* First Last Emergency Contact Phone*Relationship to Patient*Responsible PartyIf the patient is a minor (under the age of 18), the parent or guardian bringing the patient in will be listed as the guarantor. Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Social Security NumberPhoneAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Relationship to PatientAdditional InformationRace* White American lndian or Alaska Native Asian Hispanic Black or African American Native Hawaiian or Pacific lslander Other Decline Ethnicity*Hispanic or LatinoNot Hispanic or LatinoDeclinePreferred Language*EnglishSpanishChineseSign LanguageOtherPreferred Pharmacy Name & Location:* Primary Medical InsuranceInsurance Company Name*Insurance Carrier*I.d. or Policy Number*Policy Holder Name* First Last Policy Holder Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy Holder's Social Security #:*Patient Relationship to Policy Holder*Secondary Medical InsuranceInsurance Company NamePolicy Holder Name First Last Policy Holder's Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Policy Holder's Social Security #:Patient Relationship to Policy HolderConsent*I certify that I have read and agree to Central Washington Eye Clinic's (CWEC) payment policy, I am eligible for the insurance indicated on this form and I understand that payment is my responsibility regardless of insurance coverage. I hereby assign to CWEC all money to which I am entitled for medical/vision expenses related to the service performed from time to time by CWEC, but not to exceed my indebtedness to CWEC. I authorize CWEC to release any medical information to my insurance carrier or third-party payer to facilitate processing my insurance claims. I understand that failure to pay outstanding balances within 90 days of notification of the amount due will result in submission to an outside collection agency, A $35,00 returned check fee will be charged for checks returned due to insufficient funds. I choose to receive communications from CWEC by text or e-mail at the number or address stated above, including but not limited to communications about appointments, treatment, and payment, I understand that such e-mails and texts may not be secure and there is a risk that they may be read by a third party, MEDICARE BENEFICIARIES: I request that payment of authorized Medicare benefits be made to CWEC. I authorize any holder of medical information about me to release to CMS and its agents any information needed to determine these benefits or the benefits payable for related services. I have reviewed a copy of Central Washington Eye Clinic's Privacy Notice.Signature*Date* Date Format: MM slash DD slash YYYY Printed Name* First Last Date* Date Format: MM slash DD slash YYYY HIPAAAuthorization to Receive/Release Health InformationPatient Name* First Last Do you have a person or family member that you authorize to receive and discuss information regarding your personal health information (general, surgical and billing)?*YesNoIf Yes, Name* First Last If Yes, Relationship to You*If Yes, Phone Number*We keep a record of the health services we provide you. You may request to view and copy your health record; we may charge you a fee to copy those records. Our Notice of Privacy practices describes in detail how your health information may be used, disclosed, and how you can access your information. You may request a complete copy of our Notice of Privacy Practices from our reception desk.By signing below, I acknowledge the Notice of privacy practices summary.Signature*Date* Date Format: MM slash DD slash YYYY Medical InformationWhat is the reason for your visit today?*Are you allergic to or sensitive to any medications?*YesNolf yes, please list and explain:*List any medications you currently take (including eye drops, oral contraceptives, aspirin, over the counter medications and home remedies):*Social HistoryDo you currently use tobacco?*YesNoIf no, have you ever?*lf yes, amount and how long:*Do you currently use alcohol?*YesNoOccasionallyDo you currently use illegal drugs?*YesNoIf yes, what type and how long:*Review of SystemsDo you currently have or have you ever had any problems in the following areas:Asthma*YesNoChronic Bronchitis*YesNoCOPD*YesNoHeadaches*YesNoMigraines*YesNoSeizures*YesNoHeart Disease*YesNoHigh Blood Pressure*YesNoHigh Cholesterol*YesNoThyroid*YesNoDiabetes*YesNoAllergies/Hay Fever*YesNoAnaphylaxis*YesNoArthritis*YesNoRheumatoid Arthritis*YesNoCancer*YesNoOther Medical Conditions:*EmailThis field is for validation purposes and should be left unchanged.