Insurance Form

First Name:__________________________________ Last Name:_____________________________________

Street Address:_______________________________________________________________

City:___________________________ State:_______ Zip:_________________

Date of Birth:______________________ Age:_________ Male:_____Female:______

Telephone: Home_____________________ Work:______________________

Marital Status: Single, Married, Divorced, Widowed_____________________________

Recommended to Office By:________________________________________________

SSN:________________________________

Employers Name:___________________________________________________________________________________

Employer Address:___________________________________________________________________________________

Name of Spouse:___________________________________________

Spouse's Employer:_________________________________________

Spouse's SSN:_________________________________ Spouse DOB:________________________________

Are you personally responsible for payment of fees? YES:_________ NO:_________

If not, give name of person responsible: Name:______________________________________

Relationship:____________________________________

Primary Insurance Name:___________________________________________________

Policy #:______________________ Group:___________________________ Plan:__________________________

Secondary Insurance Name:_________________________________ Policy:________________________________

Authorization
The undersigned hereby authorizes the release of any information relating to all claims for benefits submitted on behalf of myself and/or dependents. I further expressly agree and acknowledge that my signature on this document authorizes my physician to submit claims for benefits for services rendered or for services to be rendered without obtaining my signature on each and every claim to be submitted for myself, and/or my dependents that I will be bound by this signature as though the undersigned had personally signed the particular form.

________________________________________ _______________________________
Signature                                                                  Date

Medicare Patients:
Statement to Permit Payment of Medicare Benefits to Provider, Physicians and Patients
I request that payment of authorized Medicare benefits be made either to me or on my behalf for any services furnished by me or in Midwest Glaucoma Center, P.C., including my physician services. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration and its agents, any information needed to determine these benefits or benefits for related services.

________________________________________ _______________________________
Signature                                                                  Date

________________________________________ _______________________________
Printed Name                                                            Medicare Number (HICN)