Returning Patients Step 1 of 2 50% Insurance InformationThank you for scheduling an exam at our office! We look forward to seeing you again, but need a little more information about your upcoming visit before we are ready to see you. This form contains confidential information and is delivered to your doctor through a secure internet connection. Please fill it out as soon as possible. IF WE DO NOT RECEIVE THIS COMPLETED FORM BEFORE YOUR SCHEDULED APPOINTMENT TIME, WE MAY NEED TO RESCHEDULE YOUR APPOINTMENT TO ANOTHER DATE/TIME. If you have any questions, feel free to call us at 502-996-7450.Patient NameFirst name Last name What are we seeing you for : Glasses Exam Contact Exam Diabetic Exam Eye Infection Eye Injury Other Will you be using insurance (please bring all insurance cards with you to your appointment): Yes -- same as last visit (no changes) Yes -- new for this visit (please complete all info below) No Vision Insurance : Avesis Davis EyeMed Passport Spectera Tricare VSP Other Subscriber Name: First Last Date of Birth: Last 4 SSN: Member ID: Group ID: Primary Medical Insurance: Aetna Anthem Humana Medicare United Health Care Other Subscriber Name: First Last Date of Birth: Member ID: Group ID: Secondary Medical Insurance (if applicable): Aetna Anthem Humana Medicare United Health Care Other Subscriber Name: First Last Date of Birth: Member ID: Group ID: CommentsIf you have any comments you would like to add, please enter them here.Digital ConsentBy including my name below, I authorize Derby City Eye Care to communicate with me via mobile phone, text message, email, and any other kind of online or digital communication. I also authorize Derby City Eye Care to provide me with digital copies of my eyeglass prescription, contact lens prescription, and medical records upon my request. I understand that digital copies are not encrypted and agree to assume the risks associated with receiving them in this manner. I also understand that I may request paper copies of these materials at any time.Name First Last Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
