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(812) 339-7995 Schedule Appointment

Home
New Patient Center
- Patient Info & Forms
Contact Us
- Appointment Request
- Prescription Refill Request
About Us
Conditions Treated
Services
Resources
- Privacy Practices
- No Show Policy
FAQ’s
Articles

(812) 339-7995 Schedule Appointment

Home

Patient Form 2

Patient Form 2

Name*

Date

Date of Birth

Age

Gender

Male Female

Address

City

Street

Zip

Home Phone

Work *

Mobile

Email *

Employer

Preferred Method of Phone Contact

Mobile Home Work

Would you like to receive notifications via text?

Yes No

NOTE: TEXT MESSAGE NOTIFICATIONS ARE AVAILABLE TO MOBILE NUMBERS ONLY

Date of Last Exam?

Where?

Marital Status:

Single Married Divorced Widowed Separated Minor Child

Student Status

Full-Time Part-Time Not a Student

If Patient is a minor , lives with

Relationship

Phone

Address

INSURANCE INFORMATION

MUST BE FILLED OUT COMPLETELY IN ORDER FOR US TO FILE YOUR INSURANCE

Primary

ID#

Subscriber Name

DOB

Relationship

Secondary

ID#

Subscriber Name

DOB

Relationship

Vision

ID#

Subscriber Name

DOB

Relationship

Subscriber's Employer

PERSON RESPONSIBLE FOR PAYMENT

IF YOU ARE RESPONSIBLE FOR PAYMENT CHECK THIS BOX

I Agree

Name

DOB

SS#

Address

City

Street

ZIP

Home Phone

Mobile

Work

I authorize the release of any medical information necessary to process insurance claims and authorize payment of medical benefits to Brinegar Eye Care. I AM FINANCIALLY RESPONSIBLE FOR ALL SERVICES PROVIDED BY BRINEGAR EYE CARE TO ME OR MY DEPENDENTS
. If BEC is not a
participating provider in my insurance plan, I understand that payment is required at the time of service.

REFRACTION FEE
A refraction is a test to obtain your best corrected vision, to determined the need for eye glasses, surgery, and/or medicine. Most medical insurance plans, including Medicare, do not cover refractions. Our office will collect the refraction fee along with any co-payment at the time of service. Any additional testing and contact lens fitting fees may not be covered under your insurance plan.

RETURNED CHECKS
A charge of $25 will be made for NSF or returned checks
. If a third party is involved to resolve payment for services provided by BEC, I agree to be responsible for collection agency fees, attorney fees, and court costs, interest or other charges incurred.

I Allow

Yes

NOTICE OF PRIVACY PRACTICES / RELEASE OF MEDICAL INFORMATION

Your medical information is personal to you and by law, Brinegar Eye Care is required to make sure that it is kept private. You may obtain a copy of our privacy policy by request.

On occasion a family member, friend, or caregiver may contact Brinegar Eye Care to inquire about your medical information. Please list those individuals to whom the information may be disclosed.

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

EMERGENCY

In case of an emergency, please contact

Name

Phone

Relationship

Name

Phone

Relationship

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

Brinegar Eye Care, LLC

Address

4001 E 3rd St Ste 8,
Bloomington, IN 47401

Phone

(812) 339-7995

Monday

9:00 am - 5:00 pm

Tuesday

9:00 am - 5:00 pm

Wednesday

9:00 am - 5:00 pm

Thursday

9:00 am - 5:00 pm

Friday

9:00 am - 5:00 pm

Saturday

Closed

Sunday

Closed

Location

Find us on the map

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Brinegar Eye Care, LLC

Address

4001 E 3rd St Ste 8
Bloomington, IN 47401

Contact Information (812) 339-7995

Contact Us

Use the form below

Name*

Email *

Phone *

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

Error!

4001 E. 3rd Street, Bloomington, IN, 47401, US

(812) 339-7995

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