For your convenience, before you visit our locations for your appointment, you may fill out and send the appropriate registration forms via email or fax – or you can complete the forms, print them out, and bring them with you.
If you are emailing the forms before your visit, email the Dupont location at Dupont@Korrect.com. There isn’t an email option for the downtown location. If you are faxing the forms before your visit, fax the Dupont visit form to (502) 736-9762; and the downtown visit form to (502) 447-3083.
Assistance on completion of any of these forms is available by calling (502) 895-2020.
PATIENT REGISTRATION FORM
If you are seeing one of our doctors at the time of your visit – please complete this form.
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NOTICE OF PRIVACY PRACTICES – HIPPA INFORMATION
Information regarding patient privacy, requiring patient review and signature.
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ADVANCE BENEFICIARY NOTICE
Fill out only if a Medicare patient. This completed form can only be faxed or printed, and brought in at the time of your visit.
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PATIENT FINANCIAL RESPONSIBILITY AND ASSIGNMENT OF BENEFITS
All patients must fill out this form.
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OPTOMAP® RETINAL EXAM ACCEPTANCE FORM
Use this form to accept an Optomap eye examination
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CONTACT LENS EVALUATION AGREEMENT
If you want an evaluation for contact lenses, please complete this form.
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These forms are also available in our offices and can be filled out at the time of your appointment.