Patient Registration

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Referred By

Internist / Family Physician

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Emergency Contact

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How would you prefer we contact you?

This is how we will send appointment reminders.

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Do you have medical health insurance?

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

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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

I request that payment of authorized Medicare benefits be made on my behalf to D.A. Wallace dba LA Sight Medical Center, PC ("LA Sight") any services furnished me by David A. Wallace, MD, M. Amir Moarefi, MD, Uday Devgan, MD or the office of LA Sight. I authorize any holder of medical information needed to determine these benefits or the benefits payable to related services. I understand that my signature below authorizes that payments be made, and authorizes release of medical information necessary to pay the claim. My signature authorizes releasing of the information to the insurer or any agency shown. In "Medicare-assigned" cases, the physician agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is only responsible for the deductible, co-insurance, and non-covered services. Co-insurance and the deductible are based upon the insurance coverage of the beneficiary and are subject to determination of the Medicare carrier.

A refraction is the measurement of your optical prescription, for the purpose of determining your best-corrected vision, and provides you with the written prescription necessary to purchase new eyeglasses and/or contact lenses. If Medicare is your primary insurance, the refraction is not reimbursed as part of the eye examination. This fee is your responsibility, and is collected at the time of your visit. The refraction fee charged by LA Sight is $75.00

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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.

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