Patient Registration

Full Name

Preferred Phone

Email

Street Address City State ZIP Code

SSN

Date of Birth

Internist / Family Physician

Physician Phone

Emergency Contact

Emergency Phone

How would you prefer we contact you?

This is how we will send appointment reminders.

Call
Text
Email

Do you have medical health insurance?

If yes, please provide your insurance card to the front desk team when you arrive for your appointment, and complete the fields below.

Yes
No

Primary Insurance Name / ID #

Secondary Insurance Name / ID #

I understand I am financially responsible to D A Wallace, Inc. (dba LA Sight Medical Center or "LA Sight") for all charges incurred as a consequence of medical care received through this office, including any charges not covered by my insurance carrier. This includes charges for refraction (prescription measurement of the eyes) that may or may not be covered by your health insurance policy. I hereby authorize the release of any information requested by my insurance carrier concerning my present illness or injury. I hereby also assign to LA Sight all money to which I am entitled for medical and/or surgical expenses relative to the services reported. I permit a copy of this authorization to remain on file and be used in place of an original signature for claims filed. I request that payment of authorized Medicare benefits be made on my behalf to LA Sight for any services furnished me by or under supervision of its physicians. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determining these benefits and process related claims accordingly.

Signature

Date

NOTICE TO PATIENTS: Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to www.mbc.ca.gov, email: licensecheck@mbc.ca.gov, or call (800) 633-2322. For more information or other languages, please visit the Board’s Notice to Consumer webpage.

The federal Physician Payments Sunshine Act requires that detailed information about payments made from manufacturers of drugs, medical devices, and biologics to physicians be available to the public. You may access this information by visiting the Open Payments database webpage.

By typing your name below you acknowledge that you have read and understand the statements above.

Print Name*

Your Signature*

Date*