Patient Registration Form

  • Date Format: MM slash DD slash YYYY
  • Financial Responsibilty

    Write "self" if appropriate
  • Date Format: MM slash DD slash YYYY
  • Insurance Information

  • I consent to treatment necessary for the care of the above named patient.

    I authorize the release of all medical records to the referring and family physicians and to my insurance company, if applicable.

    I allow fax transmittal of my medical records, if necessary.

    I take full financial responsibility for services rendered by Dr. Kohli or Dr. Inverson.

    I understand that payment of charges incurred is due at the time of service unless other defined financial arrangements have been made.

    I agree to pay all reasonable collection costs in the event of default payment.

    I further authorize and request as a one time signature that insurance payments be made directly to U.P. Ophthalmology until otherwise stated.

    By signing this statement i have consented for treatment, financial responsibility, release of medical information, and insurance authorization as long as I am under the care of U.P. Ophthalmology.
  • Date Format: MM slash DD slash YYYY
  • Please type your name.