Eye Physicians of Orange County, P.C.

LOCATIONS:  1 HATFIELD LANE GOSHEN, NY / RT 17M MONROE, NY

8 FORESTER AVE. WARWICK, NY /32 CANAL STREET PORT JERVIS, NY

REGISTRATION FORM

Which doctor will you be seeing:                                                              Date:______________

Dr..Stamm__Dr.Green___ Dr.Kates__ Dr.Burnstein___Dr.Koreen__Dr.Narula__ Dr. Winkler____

Referral Souce:__________________________E-Mail Address: ________________________

Patient Information:

First  _________________________________Last____________________________________

Gender:_Male__   Female___DOB:___________________S.S.#__________________________

Address:_____________________Apt.#_____City_________State______________Zip_______

Home Phone:___________________Work:__________________Cell:_____________________

Primary Care Physician:__________________________________________________________

Pharmacy Name:____________________________________Phone#_____________________

Emergency Contact:_______________________ Phone:________________________________  

Guarantor/Insurance Policy Holder:  If not the same as patient

 First:________________________Last:_______________________DOB:_________________

Address:_________________________________Cell Phone: ____________________________

Insurance Plan :_________________________________ ID#:____________________________

 S.S.#__________________________________________

I authorize the release of any medical or other information necessary to process a claim.  I understand and agree that I am responsible for the balance of my account for any professional services including any unmet deductible, copayments and non covered services.  I authorize payment of benefits directly to the physician..  I further understand that in the event this account is turned over to attorney for collection.  I will be responsible for a collection fee of 29% of the balance account.

 

Signature:________________________________Date:____/___/____ ­­­­SS#______/_____­­­­/________      

1 Hatfield Lane, Suite 3, Goshen (845-294-5128)  ♦  42 High St., Warwick (845-987-1203)  ♦  845 Rt.17M Monroe, NY (845-782-0129)  ♦  30 Canal St., Port Jervis, NY (845-672-3960)
Eye Physicians of Orange County, PC specialize in General Ophthalmology and Optometry; Medical and Surgical Management of Glaucoma; Pediatric Ophthalmology; Oculoplastics and Cosmetic Surgery; Cataract Evaluation and Surgery; Refractive Surgery; Pre and Post-Operative Care; Evaluation for Glasses and Contact Lenses

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