. .., REGISTRATION (PLEASE PAINn Eyelid Plastic Surgery & Reconstructive Center, LLC 185 Greenbriar Blvd. Covington, La. 70433 Telephone: (985) 898-2001 Mobile/Cell Number _ Date _ Home Phone _ Patient ~~~----------------~--- Last Name ;"SI Name Imbal Responsible Party (if a minor) _ Street Address _ City State Zip _ Sex 0 M 0 F Age Birthdate 0 Single 0 Married 0 Widowed 0 Separated 0 Divorced Patient Employed By _ Business Address _ occucanoru; Business Phone _ Spouse (or responsibleparty) Name Birthdate --'- Business Name and Address _ occupation Business Phone _ Who is responsible for this account? Relationship to Patient _ Social Security # Spouse's Social Security # _ Do you have Medical Insurance? 0 No 0 Yes ~ NameofPrima~lnsurer------------------------------------ _ If yes. Contract # Group # Subscriber # _ Name of Secondary Insurer (if any) _ Contract # Group # Subscriber # _ o Medicare o Medicaid Claim 10 # _ If Welfare. your number County 01'- _ In case of emergency,who should be notified? Phone _ How did you leam of our practice? _ Slgnal1Jre 01 tnsuree/Guardran Dale ASSIGNMENT AND RELEASE I. the undersiqned. have Insurance coverage With , ame 01 Ir surance Company and assign directly to Dr. all medical benefits. If any. otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by Insurance. I hereby authonze the doctor to release all information necessary to secure the payment of benefits. I authonze the use of this signature on all my Insurance submissions. MEDICARE AUTHORIZATION I -equest that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. for any services furnished me by that physician. I authonze any holder of medical mtormanon about me to release to the Health Care Financing Administration and ItS agents any Information needed to determine these benefits or the benefits payable for related services. I understand my Signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If "other health insurance" is Indicated In Item 9 of the HCFA-1500 form. or elsewhere on other approved claim forms or electronically submitted claims. my signature authorizes releasing of the Information to the Insurer or agency shown. In Medicare assigned cases. the phystcian or supplier agrees to accept the charge determination of the Medicare earner as the full charge. and the patient IS responsible only for the deductible. comsurance, and noncovered ser- vices. Coinsurance and the deductible are based upon the charge determination of the Medicare earner, geneflc1ary S'gnalure Jale