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PATIENT HUB

FORMS

Attention:  Before registering for our Patient Portal, please contact us for the Practice ID and security code.

 

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

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Text and Email Authorization Form

 

PEDIATRIC & STRABISMUS FORMS
For patients seeing Dr. Diora, Dr. Ellis, Dr. Jeffery, Dr. Morrison, Dr. Seidman, or Dr. Torosian 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

 

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)

 

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

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