Skip to main content
Home » Contact Us » Patient Forms » Patient Information & Insurance

Patient Information & Insurance

  • Please complete the information below and submit the form online, or if you prefer print out the form after full or partial completion, and bring it when you come to our office.

    This form contains confidential information and is delivered to your doctor through a secure Internet connection.

  • Patient Information

  • Insurance/Guarantor Information

  • In the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, I authorize Optic Gallery to do so. If applicable, I hereby authorize that payment by my insurance company be made directly to Optic Gallery for any services rendered to me. I also authorize Optic Gallery to release any information that is required to process a claim for services rendered.

    I UNDERSTAND THAT I AM RESPONSIBLE FOR CHARGES NOT COVERED BY MY INSURANCE COMPANY

  • This field is for validation purposes and should be left unchanged.