Crystal Eyes Vision Center

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 Questionnaire

Insurance

Dr. Fillmore and Crystal Eyes Vision Center are providers for…

  • Vision Service Plan (VSP)

  • EyeMed

  • Ohio Medicaid

  • Unison

  • Buckeye Community Health Plan

  • CareSource

  • Medicare

  • Medical Mutual

  • Anthem Blue Cross, Blue Shield

  • E.S. Beveridge (City of Mansfield)

  • Aetna

  • United Health Care

    • Crystal Eyes Vision Center is also pleased to announce that we offer flexible payment options with Care Credit
    Please call our office for details.

    www.vsp.com

    Patient Questionnaire

    CRYSTAL EYES VISION CENTER

    the office of

    Russell S. Fillmore, OD

    833 Lexington Avenue
    Mansfield, Ohio 44907

    (419) 756-0500

    (419) 589-EYES

    PATIENT QUESTIONNAIRE
    Please fill out the form below so that we may be better prepared for your upcoming appointment. You may email the form directly to our staff with the "Submit Form" link at the bottom of the form. This process will allow us to better serve you. THANK YOU!

    Full Name
    Date of Exam-- (mm/dd/yy)
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Home Phone
    Work Phone
    Cellular Phone
    E-mail
    Date of Birth-- (mm/dd/yy)
    Social Security Number
    Sex Male Female
    Marital Status Married Single Widowed Divorced
    Occupation
    Place of Employment
    Employed Full Time or Part-Time Full Time Part-Time
    Student Yes No
    Student / Grade
    Student / School
    How did you hear about us? Friend Family Phone Book
    Who may we thank for referring you to our office?
    Person responsible for payment of account
    Responsible party's date of birth-- (mm/dd/yy)
    Responsible Party's Social Security Number
    Medical Insurance Company
    Vision Insurance Company


    I UNDERSTAND AND AGREE THAT (REGARDLESS OF MY INSURANCE STATUS), I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE OF MY ACCOUNT FOR ANY PROFESSIONAL SERVICES RENDERED.

    I HAVE READ ALL THE INFORMATION ON THIS SHEET AND HAVE COMPLETED THE ABOVE ANSWERS.

    I CERTIFY ALL THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

    I WILL NOTIFY YOU OF ANY CHANGES IN MY STATUS OR IN THE ABOVE INFORMATION.

    I AUTHORIZE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS INSURANCE CLAIMS AND PAYMENTS OF MEDICAL BENEFITS TO DR. FILLMORE.

    I ACKNOWLEDGE THAT I HAVE BEEN GIVEN OR WILL BE OFFERED A COPY TO READ OF THE NOTICE OF PRIVACY PRACTICES FOR CRYSTAL EYES VISION CENTER AND RUSSELL S. FILLMORE, O.D.

    Copyright © 2003 - 2007 Crystal Eyes Vision Center. All rights reserved.
    Revised: 03/02/07

     

     



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