Seeing is Believing
Patient Information/Geographic Form
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How did you hear about Lehmann Eye Center?
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The above information is correct to the best of my knowledge. If applicable, I request that Lehmann Eye Center file Medicare/Insurance Claims and that payments of authorized benefits be made on my behalf to Lehmann EyeCenter/ Doctors Surgery Center for any services furnished to me by the attending physician. I authorize the release of any medical information necessary to process Medicare and any Insurance Claim. I am aware that any balance not covered by my insurancewill be my responsibility.
I authorize Lehmann Eye Center/Doctors Surgery Center to release any information regarding my Medical History, Diagnosis, Care, Treatment, or Progress to the following. We may release all information unless specified to:
5300 North Street
Nacogdoches, TX 75965
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