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

We are excited to announce that our practice is implementing a new Electronic Medical Records (EMR) System.

As we embark on this new venture, we ask that you please bear with us. We are reducing the schedules at this time to adjust for training purposes. We would like to thank all of our patrons in advance for your patience and understanding as we grow as healthcare providers.

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

COVID-19 Protocols: In accordance with CDC guidance, masks are now optional for patients and staff within our offices

during times of low community transmission levels. We support anyone who chooses to continue wearing masks while in our offices.

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

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, 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

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

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