Patient Registration Form

Patient Registration
 
 
 
 
 
 
 
 
 
 
 
 
Primary Insurance Information
Secondary Insurance Information
RELEASE OF INFORMATION CLAIM PAYMENT AUTHORIZATION
I hereby give consent to the attending physician to release anyinformation acquired in the course of examination or treatment andallow a photocopy of my signature to be used for insurance purposesonly. I give permission to release medical records or information to othermedical doctors.
The subscriber hereby gives consent for his/her insurance company(s) at its option toissue indemnity checks to the providerrendering services.
I received a copy of the MidWest EyeCenter Notice of Privacy Practices.