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.
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.
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.
The Highland Ophthalmology Patient Care Team
By Appt. Only