FORMS | NVOA

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Patients visiting the Falls Church Office: We have moved! Our new address is 6565 Arlington Blvd. Suite 250, Falls Church, VA 22042

COVID-19 Protocols: Please click here to learn about our current COVID-19 safety protocols.

Respect: We strive to show respect to every person that comes into our practice, in return, we appreciate the same. We have a zero-tolerance policy for any disrespectful or disruptive behavior. Anyone who displays this behavior will be asked to leave. Thank you.

Patients Visiting the Fairfax Office: Please click here for temporary handicap parking instructions.

PATIENT HUB

FORMS

Attention: Please do not use the duplex, or double-sided, printing option when printing forms from our website. Instead, please print one form per sheet of paper to ensure proper scanning of your forms on your appointment date.

Additionally, on the date of your appointment, you may be asked by our staff to complete and sign our Billing Forms, including our Check-In Form and/or one of our waivers. Thank you.

POLICIES

Notice of Privacy Practices

Updated February 2014

GENERAL PATIENT FORMS

For patients seeing our adult ophthalmologists or our optometrists.

New Patient Packet

Medical History Update Form

Meaningful Use Demographics Form

HIPAA Consent Form

e-Prescribing Consent Form

Insurance Waiver Form

Medical Records Release Form

Text and Email Authorization Form

QUICK LINKS

ADDITIONAL RESOURCES

American Academy of Ophthalmology (AAO) Eye Smart (English)

American Academy of Ophthalmology (AAO) Eye Smart (Spanish)

American Association of Pediatric Ophthalmology and Strabismus (AAPOS) Patient Information (Mutiple Languages)

PEDIATRIC & STRABISMUS FORMS

For patients seeing Dr. Diora, Dr. Ellis, Dr. Jeffery, Dr. Morrison, or Dr. Seidman only

New Patient Packet

Medical History Update Form

Meaningful Use Demographics Form

HIPAA Consent Form

e-Prescribing Consent Form

Insurance Waiver Form

Medical Records Release Form

Text and Email Authorization Form

Minor Consent Form

You will need Adobe Reader to access our Forms. To download this program, click here.

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