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:
- Patient Registration Form
- Privacy Consent
- Medical History Form
- Master Medicine List
- Patient Financial Policy
- Cancellation and No Show Policy
These forms are pdf files. You will need Adobe Reader to open them.
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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 participate with most insurance plans. To ensure our physicians are in network with your insurance plan, please call the member services number on your insurance card.
Please come prepared to pay your co-pay, coinsurance or deductible.
We accept Visa, MasterCard, Discover, American Express and Care Credit.
If you have a question about your insurance coverage before your visit, please contact our billing department at (800) 627-2020 and select the prompt for billing or you may send an email to email@example.com.
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.