labelle logo

New Patient / Financial Form

Please take a minute to fill out our patient registration form. This will help to expedite your visit.

After you click “Submit” at the end of the form, please be sure to wait for the confirmation message before moving to another page or closing your browser.

Patient Information



Patient Name:

Invalid Input
Nickname:

Invalid Input
Home Phone:

Invalid Input
Cell Phone:

Invalid Input
Work Phone:

Invalid Input
Email Address:

Invalid Input
Preferred Way to Contact:

Invalid Input
Local Street Address:

Invalid Input
City:

Invalid Input
State:

Invalid Input
Zip Code:

Invalid Input
Northern Address:

Invalid Input
City:

Invalid Input
State:

Invalid Input
Zip Code:

Invalid Input
Northern Telephone:

Invalid Input
Social Security Number:

Invalid Input
Birthdate (mm/dd/yyyy):

Invalid Input
Marital Status:

Invalid Input
Race:

Invalid Input
Ethnicity:

Invalid Input
Preferred Language:

Invalid Input
If other, please explain:

Invalid Input
Employer:

Invalid Input
Employer's Address:

Invalid Input
City:

Invalid Input
State:

Invalid Input
Zip Code:

Invalid Input
Occupation:

Invalid Input
Employment Status:

Invalid Input

Emergency Contact



Name:

Invalid Input
Address:

Invalid Input
City:

Invalid Input
State:

Invalid Input
Zip Code:

Invalid Input
Telephone Number:

Invalid Input

Responsible Party Information



Name:

Invalid Input
Address:

Invalid Input
City:

Invalid Input
State:

Invalid Input
Zip Code:

Invalid Input
Telephone Number:

Invalid Input

Primary Medical Insurance



Subscriber Name:

Invalid Input
Relation to Patient:

Invalid Input
Birthdate (mm/dd/yyyy):

Invalid Input
Social Security Number:

Invalid Input
Insurance Company:

Invalid Input
Telephone Number:

Invalid Input
Claims Address:

Invalid Input
City:

Invalid Input
State:

Invalid Input
Zip Code:

Invalid Input
ID Number:

Invalid Input
Group Number:

Invalid Input

Secondary Medical Insurance



Subscriber Name:

Invalid Input
Relation to Patient:

Invalid Input
Birthdate (mm/dd/yyyy):

Invalid Input
Social Security Number:

Invalid Input
Insurance Company:

Invalid Input
Telephone Number:

Invalid Input
Claims Address:

Invalid Input
City:

Invalid Input
State:

Invalid Input
Zip Code:

Invalid Input
ID Number:

Invalid Input
Group Number:

Invalid Input




How did you hear about our office?

Invalid Input



If you would like us to send information about our office to someone you know, please give us their information below.

Name:

Invalid Input
Address:

Invalid Input
City:

Invalid Input
State:

Invalid Input
Zip Code:

Invalid Input

Financial Policy

Payment for services is requested at the time services are rendered. For materials, ordered, we ask for full payment at the time of ordering. If our policies pose a financial burden, please ask to speak with the Office Manager on Accounts Coordinator.

I understand that my insurance contract is between my insurance company and me. It is the responsibility of the patient to know and understand their medical insurance benefits. If my insurance has not paid my claim within 60 days for the date insurance was billed, I will be responsible for payment. I also agree that I am responsible for any charges that my insurance company will not cover. I understand that failure to pay my account or make suitable financial arrangements may result in my account being placed in a state of delinquency. If this becomes necessary, I agree to pay all collection fees, which include but are not limited to collection fees, court fees, attorney fees and any other fees for the collection of my account balance. I also understand that is I write a check that is returned for any reason, I will be charged a fee according to Florida Statute.

Return Policy

Professional Services

Fees for professional services are non-refundable.

Glasses/Ophthalmic Products

Glasses are complex, custom-made medical devices comprised of a set of frames and spectacle lenses. In the event that a patient is not completely satisfied with the visual acuity obtained with the prescription lenses provided by Family Eye Care, the patient will be asked to return to the office for an adjustment of the glasses and, as necessary, to schedule a short prescription re-evaluation with the doctor. Family Eye Care makes every effort to provide glasses that are accurate to the prescribing doctor’s instructions.

This process must be initiated within 90 days of the original purchase date. Returns and refunds are considered by the office management on a case-by-case basis. Restocking fees may apply.

Professional Services

In the case of a prescription change for contact lenses, you may return or exchange unused contact lenses purchased from Family Eye Care within one year of the original purchase date. Merchandise must be in the original, unopened packaging. All merchandise must be in like-new condition.

By typing your name in the space provided below, means acceptance and agreement with the above policies.



Signature: (*)

Invalid Input
Date:

Invalid Input

CONSENT TO USE OR DISCLOSE HEALTH INFORMATION FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS



Patient First Name:

Invalid Input
Patient Last Name:

Invalid Input
Date:

Invalid Input

In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services, and to conduct health care operations involving our office.

We have a comprehensive Notice of Privacy Practices that describes these uses and disclosures in detail. You are free to refer to this Notice at any time before you sign this consent document. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes submission of your health information to third-party payers or insurers for claims review, determination of benefits and payment; our submission of your health information to auditors hired by third-party payers and insurers, among other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office.

When you sign this consent document, you signify that you authorize us to use and disclose your health information to treat you, to obtain payment for our services, and to perform health care operations. You can revoke this consent in writing at any time, unless we have already treated you, sought payment for our services, or performed health care operations in reliance upon our ability to use or disclose your health information in accordance with this consent. We can decline to serve you if you elect not to sign this consent form. You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or health care operations, but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I HAVE READ THIS CONSENT AND UNDERSTAND IT. I CONSENT TO THE USE AND DISCLOSURE OF MY HEALTH INFORMATION FOR PURPOSES OF TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS.

By typing your name in the space provided below, means acceptance and agreement with the above policies.



Signature: (*)

Invalid Input
Date:

Invalid Input

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:



Name:

Invalid Input
Relationship to patient:

Invalid Input
Source of authority:

Invalid Input


Invalid Input



© 2017 Family Eye Care Labelle

Please publish modules in offcanvas position.