New Patient Paperwork

New Patient Information

Welcome to Retina Associates of Kentucky. We are pleased that you and your doctor have selected us to provide services to you. On this page you will find all the information you will need to plan your visit to our office. Below are listed some general guidelines about your visit and, several forms we would like filled out prior to your visit. 

Please call our office with any questions you may have. We appreciate your cooperation and, look forward to seeing you soon.

Planning your visit
Please have a driver come with you.
Be prepared to stay several hours.
You will need dark sunglasses when leaving the office (your eyes will be dilated).

Please fill out these forms prior to your visit and bring them with you:

  1. Patient Registration Form
  2. Privacy Consent
  3. Medical History Form
  4. Master Medicine List
  5. Notice of our Privacy Policy

These forms are pdf files. You will need Adobe Reader to open them.
If you do not have Adobe Reader please click the button below
to go to to download it.

Click here to download Adobe Reader


Please bring with you:
A written list of all medications you are currently taking and the dose that you take.
A list of surgical procedures you have had, including the name of the physician(s) who performed those procedures.
Your insurance card(s).
Your photo ID.



We accept most insurances in an effort to be available for all patients. A list of the top insurances we accept is listed below for your reference. If you do not see your insurance in the list, we encourage you to call our office for verification, 1-800-627-2020, as the list is ever evolving.

Aetna Better Health of WV
Anthem Medicaid
Baptist Health Plan
Humana Caresource
KY Medicaid
Medical Mutual
Molina of Ohio
OH Medicaid
Passport Medicaid
Railroad Medicare
Tri-West / VAMC
United Healthcare
WV Medicaid
WV Molina

Updated May 2017

Please call us if you have a question about your insurance coverage before your visit.
Please come prepared to pay your co-pay or deductible insurance.
We accept Visa and Mastercard

Workers Compensation patients must bring:
The name of the employer at the time of injury.
The name of your Workers Comp insurance carrier.
Your Workers Comp claim number.
The date and time of injury.
A letter from your employer or Workers Comp insurance carrier verifying coverage for the injury or condition.