Get Shepherd Eye Center Patient Information Form

Completing the SHEPHERD EYE CENTER PATIENT INFORMATION FORM online is an essential step in receiving care at the center. This guide will provide clear, comprehensive instructions to assist you in accurately filling out the form, ensuring a smooth process for both you and the healthcare team.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to access the form and display it for editing.
2. Begin with the Patient Information section. Fill in your primary care physician's name, your full name, the date, and your social security number. Indicate your sex by circling 'M' for male or 'F' for female, and provide your date of birth.
3. Next, provide your marital status by circling one of the following options: single, married, widowed, or divorced. Fill in your address, including city, state, and zip code.
4. Enter your home phone number, cell number, and email address. Include your employer's name for record-keeping.
5. If applicable, provide your spouse's name and their date of birth in the designated fields.
6. For Responsible Party Information, if different from the patient, fill in the name, social security number, sex, address, date of birth, and both home and cell phone numbers of the responsible party.
7. In the Primary Insurance Information section, indicate the name of your insurance company, policy number, group number, effective date, expiration date, name of the insured, and the date of birth of the insured. Indicate the relationship to the patient.
8. If you have secondary insurance, repeat the process in the Secondary Insurance Information section.
9. Review and complete the Authorization for Payment section with the required signature from you or your guardian.
10. Acknowledge receipt of the Notice of Privacy Policies by signing and providing your printed name and date.
11. For patient contact preferences, choose your preferred method of communication and provide the necessary phone or email details.
12. Fill in the emergency contact section with the name, phone number, and relationship of your chosen contact person.
13. If applicable, provide names and information for the Release of Protected Health Information section, including the specifics of what can be shared.
14. Complete the Preferred Language Information, Cultural Background Information, and any questions related to guardianship or hospice care.
15. Finally, review all your entries for accuracy and completeness. Save your changes, and if you need to, download, print, or share the completed form.

Complete your documents online today for a seamless healthcare experience.