Dr. Peter Brasch - Patient Forms

Please bring the following forms and information
Click on the links below for PDFs

Medical History Questionnaire
Patient Registration Form
Signature On File
Notice of Privacy Practices
A list of your current medications
Financial & Payment Policy
HIPPA Consent Form
Vision Versus Medical Diagnosis
Your current insurance card(s)
Photo identification
Your eyeglasses
Contact lens packaging with prescription parameters
Your referral or authorization number if required by your insurance.

Thank you for choosing Peter C. Brasch, MD, for your eye care. We would like to take this opportunity to welcome you as a patient and introduce you to some of our policies and procedures.

To prepare for your upcoming appointment, please print and then complete the forms listed below. Properly filled out forms will help the front office staff to expedite the organization of your chart and allow you to be seen by the doctor in a timely manner.

During your visit you may have dilation drops placed in your eyes to help the doctor examine you. We will provide you with disposable sunglasses as you check out if you need them. If, however, you are unsure of your ability to drive while dilated, you may want to bring a driver with you.

We participate with many insurance carriers and are happy to file your insurance for covered services. We ask that any copayments be paid at the time of service. For non-covered services or products, payment is expected at the time of service. Credit cards are gladly accepted. If you have any questions regarding your health insurance coverage, please contact your health insurance company prior to your visit.

Kindly give us 24 hours notice if you need to cancel or reschedule your appointment, so we may offer this time to another patient.

Once again, we welcome you and your family as patients. We are dedicated to making your experience here a pleasant one. Please feel free to contact the office with questions you may have.

Sincerely,
Peter C. Brasch, MD, and Staff