New Patient Information

2222 West Division Street Suite 135

Chicago, IL 60622

A 24 Hour Cancellation Notice Required

Thank you for choosing Winter Park Eye Center! We appreciate the trust you have placed in us and will make every effort to honor that trust through our commitment to providing excellent eye care.

In an effort to serve you in a more efficient manner, please complete the enclosed patient registration form prior to your appointment and bring it with you or email to fmarchan@wickerparkeye.com.

To make this process more convenient, please type your responses directly on the forms. On the day of your appointment, please bring your forms, along with the following:

  • Driver’s license or other photo identification
  • All of your current medical insurance identification cards and be prepared to pay your co-pay
  • A complete list of medications and supplements (including over the counter drugs) that you are currently taking, including dosages and frequency of each
  • A list of the pharmacy(s) you use, including their address and phone number
  • All of your current eyewear and sunglasses
  • A referral form, if you are a member of an HMO

The time spent for your exam and/or testing may vary, according to your individual needs, so please allow a minimum of one hour and a half for your visit.

Please remember, if for any reason you are unable to keep your appointment, we require a 24 hour cancellation notice prior to your appointment time, by calling our reception desk. We will be more than happy to reschedule your appointment for a more convenient time.

As always, the staff at Wicker Park Eye Center look forward to continuing to provide you with complete medical services and wishes to thank you for entrusting us with your eye care.

Please view our entire webpages for further information about our practice, including: directions, locations, and office hours.

Complete if under 18 years of age or a student:
Insurance Information/Billing:
Primary Insurance:
Secondary Insurance:
Please note: Referrals are required for all HMO and Worker’s Compensation patients
FINANCIAL ASSIGNMENT/AGREEMENT AND OTHER UNDERSTANDING:
1. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid for by your insurance.
2. I request that payment of authorized Medicare and/or insurance benefits be made on my behalf for any services furnished me. I authorize any holder of medical information about me to release to the Health Care Financing Administration, its agents, or any insurance carrier I may have, any information needed to determine these benefits or the benefits payable for related services.
3. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release all information necessary to secure the payment.
4. The charge for a refraction (measure for eyeglasses) is $35.00 and may not be covered by my insurance.
5. I allow fax transmittal of my medical records if medically necessary.
6. I consent to have my eyes dilated for my exam when the doctor deems it necessary. I understand that this can affect my vision and my ability to drive a car or perform other functions dependent on my vision.
Please indicate if you use the following substances:

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