Insurance & Payment Information

Insurance & Payment Information

Please complete this form before your scheduled appointment.

This information will help us serve your eye care needs more effectively and efficiently. If you have any questions at any time, please feel free to call us.
Primary Insurance
Insured’s Name
Relationship to Patient
Insured’s Birthdate
MM slash DD slash YYYY
Soc. Sec. #
Occupation
Employer
Date Employed
Insurance Company
Identification #
Group #
Ins. Company Address
Deductible $
Amount Used $
Max. Yearly Benefit $
Secondary Insurance
Insured’s Name
Relationship to Patient
Insured’s Birthdate
MM slash DD slash YYYY
Soc. Sec. #
Occupation
Employer
Date Employed
Insurance Company
Identification #
Group #
Ins. Company Address
Deductible $
Amount Used $
Max. Yearly Benefit $
Payment
For your convenience we offer the following methods of payment, please check which you prefer
- Cash
- Personal Check
- Credit Card
- Visa
- Mastercard
- I wish to discuss the office’s payment policy
Payment is expected as services are rendered. A service charge of $5.00 is added to all balances not paid within 30 days of the billing date. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect this balance or any future outstanding account balances.

I authorize the release of any information including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such care to third-party payers and/or other healthcare practitioners. I authorize and request my insurance company to pay directly to Della Porta Eyecare, LLC. insurance benefits otherwise payable to me. I also authorize Dr. Della Porta to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

In the event that this claim is denied by my insurance company, I agree to pay the full amount not covered within thirty days of such denial.
Signature
Date
MM slash DD slash YYYY
Personal Informations
All information is strictly confidential.
Date
MM slash DD slash YYYY
Phone
Name
First Last
Nickname
Sex
- Male
- Female
Marital Status
- Minor
- Single
- Married
- Divorced
- Widowed
- Separated
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Birth Date
MM slash DD slash YYYY
School
Employer
Occupation
Race
Preferred Language
Email (if over 16)
May we contact you by email?
- Yes
- No
Referred by
Responsible Party
Who is responsible for the payment of this account?
Name
First Last
Relationship to patient
Birth Date
MM slash DD slash YYYY
Phone
Driver’s License #
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employer
Occupation
Telephone
Where do you prefer to receive calls?
- Home
- Work
- Cell Phone
When is the best time to reach you?

: Hours

Minutes

AM/PM
When is the best days to reach you?
- Monday
- Thuesday
- Wednesday
- Thursday
- Friday
- Saturday
- Sunday
Home Phone
Work Phone + Ext
Cell Phone
Whom should we contact in case of an emergency?
Name
First Last
Relationship
Phone Number
Comments
This field is for validation purposes and should be left unchanged.