Patient Registration

Medical Information

Who referred you to this office?

Do You Have A Primary Care Physician?

Is This A Work-Related Injury?

Insurance Information

Medical Insurance Primary:

Medical Insurance Secondary:

Do You Have A Vision Plan?

Subscriber, If Other Than Patient

Do You Have A Health Spending Account?

Read & Sign

I AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO ASSOCIATE OPHTHALMOLOGISTS AND AUTHORIZE THE RELEASE OF MEDICAL INFORMATION NECESSARY TO PROCESS MY CLAIMS. I ACKNOWLEDGE THAT I AM RESPONSIBLE FOR OBTAINING A REFERRAL (OR WHERE APPLICABLE, NOTIFYING MY PRIMARY CARE PHYSICIAN) PRIOR TO MY VISIT AND THAT ALL COPAYMENTS, DEDUCTIBLES AND NON COVERED SERVICE ARE MY RESPONSIBILITY. I HAVE REVIEWED AND RECEIVED A COPY OF ASSOCIATE OPHTHALMOLOGISTS, NOTICE OF PRIVACY PRACTICES.

Initial

Please retype your name for your signature

Date

Thank You!

We've received your Patient Registration submission. Our team has been notified and will review this information as soon as possible to incorporate into our confidential records. If you have any additional questions at this time, please call our offices during business hours for assistance.

Patient Demographics

Medical Information

Insurance Information

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Thank You!