Jamie Rose EyeWear 11414
For your convenience we have office locations in Queens, Brooklyn, Bronx and Long Island.
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Patient Resources

Below you will find forms that are generally filled out in the office during your initial consultation:

  • Demographic Form
  • Medical Questionnaire
  • HIPPA Release Form

What to bring for your initial visit:

  • Any medical records pertaining to your current injury including any MRI reports, CT scan reports, X-Ray films and reports, physical therapy progress notes, etc.
  • Your No-Fault, Workers' Compensation Insurance information including:
    • Insurance company name
    • Insurance company address
    • Insurance company representative name and phone number
    • Claim number (for No-Fault accidents) or carrier case number and WCB number (for Workers' Compensation accidents)
    • Name of Insured, address and the policy number (for No-Fault accidents)

Forms

Patient Consent Form

Registration Form

Medical Questionnaire

Authorization to Disclose Health Information

Assignment Of Benefits Form

Office locations in Queens, Brooklyn, Bronx, Long Island and New Jersey | Orthopaedic Website Design