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FOR MEDICARE AS SECONDARY PAYOR: Please provide the following information.

POLICYHOLDER NAME: (of Primary Insurance Policyholder)*

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EMPLOYER: (of Primary Insurance Policyholder)*

AUTHORIZATION TO RELEASE INFORMATION

I HEREBY AUTHORIZE HIGHLAND OPHTHALMOLOGY ASSOCIATES, L.L.C. TO FURNISH THE INSURED’S INSURANCE COMPANY ALL INFORMATION WHICH SAID INSURANCE COMPANY MAY REQUEST CONCERNING MY CLAIMS.

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ASSIGNMENT OF INSURANCE BENEFITS

I HEREBY AUTHORIZE ALL INSURANCE BENEFITS TO BE PAID TO SAID DR. OF HIGHLAND OPHTHALMOLOGY ASSOCIATES L.L.C. FOR SERVICES RENDERED. I UNDERSTAND THAT IF A SERVICE IS NOT COVERED BY MY INSURANCE THAT I AM FINANCIALLY RESPONSIBLE FOR SAID SERVICE. IF MY INSURANCE PLAN REQUIRES A REFERRAL AND I ARRIVE WITHOUT ONE, I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR PAYMENT FOR SERVICES.

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Thank you for registering as a new patient with Highland Ophthalmology.

We will contact you as quickly as possible to confirm your registration.

If you have an immediate request, please call +1 (845) 562-0138.

Best Regards,

The Highland Ophthalmology Patient Care Team

Highland Ophthalmology has been providing Specialty Eye Care Services including Cataract, Cornea and Glaucoma surgery in Orange County, NY and the Greater New Windsor area since 1997.

140 Executive Drive
New Windsor, NY 12553

(845) 562-0138

(845) 562-0147

Office Hours

Monday: 8:30am–5:00pm

Tuesday: 8:30am–5:00pm

Wednesday: 8:30am–5:00pm

Thursday: 8:30am–7:00pm

Friday: 8:30am–5:00pm

Saturday: 9:00am–Noon

By Appt. Only

Services

Traditional Cataract Surgery
Femtosecond Laser Cataract Surgery
Glaucoma Treatment
Corneal Transplants
PROKERA® Corneal Treatment
Biotissue AmnioGraft®
Corneal Cross-Linking
Dry Eye Disease
LipiView® II Interferometer
LipiFlow® Thermal Pulsation
Optometry
Contact Lens Fitting
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