*Please include Patients marital status, Insurance Company telephone number, Name, date of birth and SSN of the insurance subscriber, Group number and Information on your Vision plan if any.
*Bring all insurance cards and picture ID at time of appointment.
*If needed please remember to bring your referral and all applicable copayments.
Please bring this form to your appointment. You can also fax this form to 212-673-7257 or email to drchang4youreyes@hotmail.com for faster service.
