760-320-8497

Medical History Questionnaire

Registration Form – Please complete form entirely



MaleFemale


Address




Emergency Contact


YesNoRetired

Full TimePart Time

Insurance Information

YesNo

YesNo

YesNo


Release of Information

I authorize the office to speak to the following people regarding my financial account, appointments, lab results, and test results





HIPPAA PRIVACY RIGHTS AND AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

I have read the HIPPAA rights and authorization statements and give my consent for disclosure of my medical records related to treatment.


PLEASE STOP at the CHECK-OUT COUNTER before leaving our office

Co-pays are required on the date of service. As a part of our service we will submit your insurance claims, but cannot assure payment. You are fully responsible for unpaid balances for products purchased and services rendered.
NO Personal checks accepted


RELEASE OF INFORMATION AND ASSIGNMENT OF BENEFITS DECLARTION

I hereby authorize release of any medical information necessary to process my insurance claim and also ASSIGN to the DOCTOR all payments from MEDICARE and/or other Insurance provider(s) for services rendered. I understand and agree to the above conditions.


INSURANCE ACKNOWLEDGEMENT

I understand that it is my responsibility to notify Desert Ophthalmology of any changes to my insurance. Failure to do so may reflect a balance on my account with Desert Ophthalmology


Forma de Registro – llene la forma completa



HombreMujer


Direccion




Contacto de Emergencia


SiNoRetirado

Tiempo CompleteParcial

Informacion de Seguro

SiNo

SiNo

SiNo


Release of Information

I authorize the office to speak to the following people regarding my financial account, appointments, lab results, and test results





DERECHOS DE PRIVACIDAD HIPPA Y AUTORIZACION PARA LA DIVULGACION DE INFORMACION DE SALUD PROTEGIDA

He leido los derechos HIPPA y declaraciones de autorizacion y doy mi consentimiento para la divulgacion de mis registros medicos relacionados con el tratamiento


Favor de parar en el mostrador antes de salir de nuestra oficina.

Los copagos son necesarios en la fecha de servicio. Como parte de nuestro servicio vamos a presenter sus reclamaciones de seguro, pero no podemos asegurar el pago.Usted es completamente responsable de los saldos pendientes de pago de los productos adquiridos y los servicios prestados
No se aceptan cheques personales


DIVULGACION DE LA INFORMACION Y LA ASIGNACION DE BENEFICIOS DECLARADOS

Autorizo la entrega de cualquier informacion medica necesaria para procesar mi reclamo de seguros y tambien asignan al medico todos los pagos de Medicare y/ otro proveedor(s) de seguro por los servicios prestados.Entiendo y estoy de acuerdo con las condiciones anteriores.


RECONOCIMIENTO DE SEGUROS

Entiendo que es mi responsabilidad notificar Desert Ophthalmology de cualquier cambio en mi seguro. De no hacerlo podria reflejar un saldo en mi cuenta con Desert Ophthalmology.


Find Us

1180 N. Indian Canyon W100
Palm Springs, CA 92262


Hours:

Monday-Friday 8-5 (closed 12-1)
Saturday-Sunday Closed

72650 Fred Waring Drive, Suite 106
Palm Desert, CA 92262
Print out directions


Hours:

Thu-Fri 1:30-5

Get in Touch!

760-320-8497
drg@deserteyedoc.com
Schedule an Appointment