Atlanta Oculofacial Plastic Surgeons Logo mark Atlanta Oculofacial Plastic Surgeons Logo

Address: 755 Mount Vernon Highway, NE
Suite 210
Atlanta, GA 30328
Telephone: 404-480-4008
Fax: 404-480-4007

Patient Information Form



Patient Information






M F








Contact Information and Consent

Home    Cell    Work   

Yes     No

Home    Cell    Work   

Yes     No

Yes     No

Yes     No

(Please note: email is not a secure method of communication. Health Information sent via email may not be private.)
Yes     No


Referal Source/PCP

Facebook Insurance Company/Plan Our Website Internet Search Friend/Family Other:



Demographics

White Black American Indian Hawaiian Other

Not Hispanic/Latino Hispanic/Latino No answer


Single Married Divorced Separated Widowed Partnered

Yes     No

Yes     No


Emergency Contact Information




Employment Status
Employed    Retired    Homemaker    Full-time Student    Part-time Student    Unemployed



Insurance Information
(Please give your insurance card(s) and identification card/driver's license to the receptionist)





Self Spouse Child Other






Self Spouse Child Other



Consent for Evaluation and/or Treatment
By signing, I am giving my consent to Atlanta Oculofacial Plastic Surgeons, Dr. Brent A. Murphy, for evaluation and/or treatment. Once I have been examined, I understand that I will be informed of any recommendations for treatment in the office and/or surgery, diagnostic procedures or treatments and given the option to accept or decline.





I have read and understand the information on this form. By entering my name in the signature box above and clicking the checkbox, I acknowledge receipt and accept the terms.



Managed Care/HMO Patients
I understand that it is my responsibility to obtain a valid referral from my primary care physician. I understand that if I do not obtain or have a referral on file that I may be held financially responsible for services received. I further understand that I am responsible for services that are considered non-covered expenses by my insurer.


I have read and understand the information on this form. By entering my name in the signature box above and clicking the checkbox, I acknowledge receipt and accept the terms.



Assignment of Benefits
I request that payment of authorized medical benefits is made on my behalf directly to Atlanta Oculofacial Plastic Surgeons for service(s) furnished to me. I authorize Atlanta Oculofacial Plastic Surgeons to release any medical information to my health insurance carrier and/or its legitimate agents that is necessary to process related health insurance claims and/or to verify plan benefits in accordance with HIPAA health information standards. I authorize payment of service(s); otherwise payable to me under the terms of my private, group employer’s/group health insurance plan, or Medicare directly to Atlanta Oculofacial Plastic Surgeons. I hereby authorize that a copy of this form to be valid as the original.


I have read and understand the information on this form. By entering my name in the signature box above and clicking the checkbox, I acknowledge receipt and accept the terms.



HIPAA/Privacy
Please tell us with whom we can discuss your protected health information/appointment details with:














I have read and understand the information on this form. By entering my name in the signature box above and clicking the checkbox, I acknowledge receipt and accept the terms.





(Form submission may take a few seconds to transmit. No need to re-submit)