CT Center for Sight

General Information Questionnaire

* Required Information

Patient's Name:

Last Name: *		First Name: *	Middle Initial:
Street Address:*

City *

State

Zip Code *

Date of Birth: *

Age: *

* M F

* Marital Status:
Married	Single
Divorced	Windowed

Home Phone: *

Cell Phone:

Email:

* Employed Full Time Employed Part Time Student Full Time Student Part Time

Employer's Name:		Occupation:
Business Phone:		Ext.

* Spouse or Parent Name:
Employer's Name:		Work #:
* Family Doctor's Name:		Referred By:

NOTIFICATION REQUIRED BY THE FEDERAL GOVERNMENT

Privacy Notification and Insurance Authorization
I authorize the routine release of my medical information for purposes of treatment, billing and routine health care operations. I understand that my medical information will not be released for any other purpose without my consent. I request that payment of authorized health care benefits be made to the Providers of Manchester Ear, Nose & Throat Center, LLC. I authorize any medical information about be be released to my health insurance agent any information needed to determine the benefits payable for related services. I am aware that I am responsible to understand my individual insurance benefits and that I am liable for any non-covered services.

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