Menu
?
Patient Portal
Quality Reporting
Home
About Us
When You Should See Us
Location
Guardian of Excellence Award
New Patient Forms
Privacy Notice
Patient Information
Patient Health
Printable Versions
Patient Information
What to Expect at Your Exam
General Billing
Insurance
Preoperative Instructions
Understanding Your Surgery Billing
Postoperative Instructions
Amsler Grid
Optical Shop
Medication Refills
Pay Your Bill Online
Medical Information - Website
Medical Information - Literature Search Engine
Patient Portal
Quality Reporting
Home
About Us
New Patient Forms
Privacy Notice
Patient Information
Patient Health
Printable Versions
Patient Information
Optical Shop
Medication Refills
Pay Your Bill Online
Medical Information - Website
Medical Information - Literature Search Engine
631 Saint Anne St., Suite 103
Rapid City, SD 57701
605.343.4120
Contact Us
Home >
New Patient Forms
> Patient Information
Patient Information
Please fill out the form below and click "submit".
Patient's First Name:
*
Patient's Last Name:
*
Patient's Middle Initial:
*
Phone (Home):
*
Phone (Work):
*
Phone (Cell):
*
Street Address:
*
City, State, Zip:
*
Email Address:
*
May we contact you via email?:
Yes
No
Social Security Number:
*
Date of Birth:
*
Sex:
Male
Female
Name of Spouse (if applicable):
Preferred language:
Ethnicity:
Race:
Employer:
*
Occupation:
*
Business Address:
*
Family Physician:
*
Pharmacy:
City, State of Family Physician:
*
Party responsible for payment if other than above:
Relationship:
Nearest Relative/Friend (not living with you):
*
Relationship:
*
Address:
*
Phone:
*
NAME OF PARENT (if patient under age 18):
Insurance Information
MEDICARE #:
MEDICAID (T-19)#:
Primary or Medicare Supplement
Name:
Address:
Employer Name & Group Policy#:
ID#:
Policy Holder:
Policy Holder’s Date of Birth:
Secondary
Name:
Address:
Employer Name & Group Policy#:
ID#:
Policy Holder:
Policy Holder’s Date of Birth:
By checking this box, I request that payment of insurance or government benefits be made either to me or on my behalf to Dr. Scott G. Eccarius for any service furnished to me by him. I understand that I am responsible for any amounts not paid by my insurance. I also authorize Dr. Eccarius to release medical records and information about me to determine benefits and procure payment.
Acknowledge:
*
Yes
PATIENT OR GUARDIAN NAME:
*
DATE:
*