Patient Registration Form

It is the policy of this office to keep your information confidential and we require your permission to release information to another person. If you should need your medical records released, a form will need to be signed by you requesting that we do so. However, by signing below you are giving us permission to release your information to insurance carriers and any doctor whom we refer you to.

I understand I am responsible for providing the correct medical and/or vision insurance information for the date of service on or before services are rendered and acknowledge that I will be responsible for any services not covered, for co-pays or co-insurance. I acknowledge that I received a copy of our Notice of Privacy Practices. I understand that you will bill the medical and/or vision plans for services and/or products provided by this office on my behalf whenever appropriate to do so. I understand that my bill today may not be the final amount and I am responsible for the entire bill if my insurance company does not pay the remaining balance.

If you must change your scheduled appointment time please give us at least 24 hour notice. Appointments canceled less than 24 hours prior to your scheduled timed or missing an appointment will result in a $50.00 fee.