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 any information acquired in the course of examination or treatment andallow a photocopy of my signature to be used for insurance purposes only. I give permission to release medical records or information to other medical doctors.
The subscriber hereby gives consent for his/her insurance company(s) at its option to issue indemnity checks to the provider rendering services.
I received a copy of the MidWest EyeCenter/MidWest Eye Surgery Center's Notice of Privacy Practices. (HIPAA regulation requirement); Patient's Rights & Responsibilities, Advance Directives Policy & Financial Disclosure (Medicare's Conditions of Coverage requirement).