Witt Eye Centers Patient Registration

  • Patient Information

  • Date Format: MM slash DD slash YYYY
  • Responsible Party - patients under the age of 18 cannot be guarantor

  • Date Format: MM slash DD slash YYYY
  • Primary Insurance

  • Date Format: MM slash DD slash YYYY
  • Secondary Insurance

  • Date Format: MM slash DD slash YYYY
  • I certify that I have read and agree to the Witt Eye Ceters (WEC) payment policy. I authorize WEC to bill my insurance company for services provided and agree to be responsible for any charges not covered. I authorize WEC to release any medical information to my insurance carrier or third party payer processing my insurance claims. I understand failure to pay outside balances within 90 days of notification of the amount due will result in submission to an outside collection agency. I understand that if I default on my account. WEC may not allow me to schedule future appointments.
  • Date Format: MM slash DD slash YYYY