New Patient:

Please print out the form and fill it out by hand.

Completing this form at home will speed-up your first office visit!

If you have any questions please call (970) 352-6688 or email info@colorado-eye.com

Link to Spanish New Patient Form

Thank you!

DRS. WELCH & UYEMURA, LLC

PATIENT INFORMATION

(Please print)

PERSONAL INFORMATION

Today's Date:________________

Name ________________________ _______________ _________ Social Security No.________ - ________ - ________

Last First MI

Mailing Address_____________________________________ City_____________________State_______Zip____________

Home Address ____________________________________ City_____________________State_______Zip____________

Home Phone ( ) ______ Work Phone ( ) ____________ Employer ___________________

Birth Date_______________________ Current age: _______ Male _____ Female ______

Marital Status: Married ____ Widow (er) _____ Spouse's Name __________________ Spouse's SS# ____________

Single____ Divorced

Emergency contact not living with you:

Name ________________________________ Phone ( ) ______ - ____________ Relationship____________________

Personal physician:

Name _____________________________________ Address or phone __________________________________________

Referred by:

Name _____________________________________ Address or phone __________________________________________

BILLING INFORMATION FOR RESPONSIBLE PARTY

(Please fill in the information below ONLY if patient is NOT RESPONSIBLE PARTY or patient is a MINOR):

Name __________________ _______________ ____________ Social Security No.________ - ________ - ________

Last First MI

Mailing Address___________________________________ City_____________________State_______Zip____________

Home Phone ( ) _____ - _________ Work Phone ( ) _____ - ________ Relationship to patient________________

EMPLOYMENT INFORMATION

Employed [ ] --> Name of employer_________________________________________________________

Address____________________________ City___________State______Zip__________

Phone ( ) _____ - ___________ Supervisor's Name__________________________

Is this a Worker's Comp Claim? No [ ] Yes [ ] Claim # ________________

Date of Injury/Accident? ______________

Is this an auto accident? No [ ] Yes [ ]

Retired [ ] Unemployed [ ] Disabled [ ] --> Name of last employer_________________________________________

Student [ ] --> Name of school __________________________________________________ Continued on back -->

INSURANCE INFORMATION

(Please bring your insurance card on your first visit)

Primary Insurance Name of Carrier________________________________________________

Address _____________________________________________________

City _____________________________ State__________ Zip___________

Phone ( ) ______ - ___________ Policy # _________________ Group#______________

Policy Holder's Name______________________ Relationship to Patient_________________

Second Insurance Name of Carrier________________________________________________

Address ______________________________________________________

City _____________________________ State__________ Zip___________

Phone ( ) ______ - ___________ Policy # _________________ Group #______________

Policy Holder's Name______________________ Relationship to Patient_________________

Please let us know if you have more than two insurance policies.

LIFETIME SIGNATURE AUTHORIZATION

Your signature on the following Lifetime Signature Authorization will enable us to submit all insurance claims for you,

With benefit payment made directly to our office. It acknowledges your responsibility for obtaining any necessary referrals. It acknowledges your acceptance of financial responsibility for charges not covered by your insurance carriers.

I request that payment of authorized insurance benefits by Medicare, Blue Cross/Blue Shield or other insurance companies be made on my behalf to Drs WELCH & UYEMURA LLC for any services furnished by Drs. Welch and/or Uyemura.

I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents or other healthcare provider that may render services or supplies that may request the information for purposes of treatment or billing, any information needed to determine these benefits, or benefits payable for related services.

I hereby release Drs. Welch & Uyemura, LLC, its agents and employees, from all responsibility or liability

that may arise from the release of such records.

I am aware that if I am to obtain a referral from my Primary Care Physician or insurance company in order to receive specialty care and have not done so and still receive service without the required referral, that I agree to accept full financial responsibility for any charges I incur.

The undersigned certifies that he/she is the patient or the duly authorized representative of the patient, and agrees to these terms.

____________________________________________________ ______________

(Patient, or Parent, or other person authorized to consent for a patient) Date