Eye Center of Connersville

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • If the patient is a minor, the following must be complete:

  • Date Format: MM slash DD slash YYYY
  • All patients and/or responsible parties, please complete the following:

  • Date Format: MM slash DD slash YYYY
  • I hereby authorize my Insurance carrier(s) to submit payment for services provided to me directly to Whitewater Eye Centers and/or Whitewater Surgery Center. I authorize any holder of medical information about me to release to my insurance carriers any information needed to determine benefits payable for related services. I request payment of authorized Medigap benefits as applicable to be released to Whitewater Eye Centers and/or Whitewater Surgery Centers. I understand that I am responsible for payment of services and failure to pay amounts owed by me may be subject to collection fees of up to 50% of the delinquent amount and/or attorney and court fees as applicable.

    I hereby acknowledge receipt of the Whitewater Eye and Surgery Center Patient Privacy notice issued on the date below.

    Date Format: MM slash DD slash YYYY