Patient Registration

Cataract Care

  • This is how we will send appointment reminders.

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

  • 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.