HIPAA Acknowledgment

• Review the "Notice of Privacy Practices" section. Download, print and sign the form and bring it with you to the eye exam appointment. A signed acknowledgment is a Federal requirement.

Confidential Patient Information

• Download, print and fill out the medical and insurance information sheets. Bring them to the eye examination

Records Transfer From Another Doctor

• Use this form if you want us to have records from another doctor

Referral From An HMO's PCP

• We need the name, address, phone and fax number of your primary care physician for medical office visit or procedures if you have an HMO.

all forms are in Adobe Acrobat PDF format, if it is not installed, please visit the Acrobat website and install Acrobat Reader.