Cedar Springs Eye Clinic

2525 Lucas Drive, Building 3 | Dallas, TX 75219 | (P) 214.528.7354 | (F) 214.528.7387 | www.opt.uh.edu/csec

REGISTRATION FORM APPOINTMENT DATE:

NAME: DATE OF BIRTH:

ADDRESS: SS#:

CITY/STATE/ZIP: PHONE #:

Please read the statements below and initial ALL that apply to you. _____ I DO have insurance coverage and will provide a copy of my card.

_____ I DO NOT have Medicaid or Medicare.

_____ I AM a resident of the Dallas Housing Authority and will provide proof of current residency.

_____ I AM currently involved in a Residential, Transitional, or Assistance Program and will provide

proof of participation.

_____ I have Medicare and I am financially unable to pay any fees not covered by Medicare (This

indicates that you are asking for a financial waiver for fees not covered by Medicare. If you

do not initial this you will be required to pay fees not covered by Medicare.)

* All services, excluding glasses, are provided on a sliding scale based on income. In order to qualify

for a reduction in cost you must provide the following information.

Number of people in Household: _____________ Yearly Household Income: $_________________

________________________________________________________________________________ By signing below I acknowledge that I have read, had explained, and/or given the opportunity to

review a copy of the NOTICE OF PRIVACY PRACTICES and agree to the terms and provisions of the

Cedar Springs Eye Clinic privacy policies.

If applicable, I agree also to assign insurance benefits and give permission to file claims on my behalf

for any services rendered at this facility.

I agree to the terms explained to me above ____________________________________ Patient Signature

____________________________________

Signature-Parent/Guardian

____________________________________

Date