Please complete registration form below or print PDF at the bottom of this page and bring completed form(s) to your appointment.

You may also email the forms to us in advance of your visit at:

Registration Form:

Last Name

First Name

Middle Name

Birth Date

Language

Race

Ethnicity

Street Address

City, State, and Zip Code

Primary Insurance

Policy #

Group #

Secondary Insurance

Policy #

Group #

Home Phone

Cell Phone

PAYMENT AUTHORIZATION: I authorize payment of medical benefits to Ophthalmic Consultants of Rockland, MD, PC, for services rendered. I authorize this office to furnish my insurance carriers with any information relevant to my claim, and to make direct payment when accepted.

Check box to agree

TREATMENT WAIVER: I properly dated, then I will be responsible for payment of these charges and can be billed directly. I also understand that certain examinations, including reagree that if Ophthalmic Consultants of Rockland treats me or my child and I do not obtain the required referral form, properly dated, then I will be responsible for payment of these charges and can be billed directly. I also understand that certain examinations, including refraction(i.e., vision testing for glasses), may be a non-covered service by my insurance company. Such changes will be my responsibility and may be non-reimbursable by insurance.

Check box to agree

MEDICARE RELEASE: I request that payment of authorized Medicare benefits be made either to me or on my behalf to Ophthalmic Consultants of Rockland for any services furnished me by physician or supplier. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.

Check box to agree

1. Registration Forms (you may print the PDFs below and bring completed forms to your appointment or email completed forms to registrationforms@ocreyemd.com):

Office Registration Form

HIPAA

2. Registration Form (Spanish):

Download English/Spanish