Patient Forms

New Patient Information

1: Preparing For Your Visit
For your convenience, the forms required for your initial visit to our practice are listed below. We encourage our patients to print each form and fill in the required information. Please bring the forms with you to your appointment.

Adult Patients

Please complete the Medical History Form.

Please complete the New Patient Questionnaire.

Pediatric Patients

Please complete the Pediatric Medical History Form.

Please complete the New Patient Questionnaire.

Please download a copy of the Medical Record Release Form

Please download a copy of the insurance providers we accept.

Surprise Billing Protection - Download Here

You should also bring the following items when you come for your appointment:

  • your insurance or health coverage card(s)
  • a list of any eye drops or other medications that you are currently using
  • your eyeglass and/or contact lens information (bottles or boxes in which the contact lenses are packaged)

2. Obtaining Insurance Authorization
Please be sure to obtain authorization from your insurance provider prior to your appointment. If you have a question regarding obtaining authorization for your visit, don’t hesitate to call our office and ask for Patient Services. We would be happy to assist you in any way that we can.

3. Information to Keep in Mind
Comprehensive eye examinations normally require one to one-and–a-half hours for new patients. Dilation of your pupils may be required for the examination. As the effect of dilation can take a few hours to wear off, it is best that you do not plan to drive or read immediately after the appointment. Ocular evaluations may also include visual field testing, optic nerve analysis and possibly other specialized corneal or glaucoma testing. These tests may require more time to complete.

Any required co-payments and deductibles will be collected from you as indicated by your health plan. Payment is requested at the time of the visit for any co-payments, deductibles, or services not covered by your health care plan. Payment may be made by cash, check, MasterCard, Visa or Discover.

Your Rights and Protections Against Surprise Medical Bills

When you get emergency care or are treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from balance billing. In these cases, you shouldn’t be charged more than your plan’s copayments, coinsurance and/or deductible. 

What is “balance billing” (sometimes called “surprise billing”)? 

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, like a copayment, coinsurance, or deductible. You may have additional costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network. 

“Out-of-network” means providers and facilities that haven’t signed a contract with your health plan to provide services. Out-of-network providers may be allowed to bill you for the difference between what your plan pays and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your plan’s deductible or annual out-of-pocket limit. 

“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider. Surprise medical bills could cost thousands of dollars depending on the procedure or service. 

You’re protected from balance billing for: 

Emergency services 

If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most they can bill you is your plan’s in-network cost-sharing amount (such as copayments, coinsurance, and deductibles). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services. 

Certain services at an in-network hospital or ambulatory surgical center 

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers can bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed. 

If you get other types of services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections. 

You’re never required to give up your protections from balance billing. You also aren’t required to get out-of-network care. You can choose a provider or facility in your plan’s network. 

When balance billing isn’t allowed, you also have these protections: 

  • You’re only responsible for paying your share of the cost (like the copayments, coinsurance, and deductible that you would pay if the provider or facility was in-network). Your health plan will pay any additional costs to out-of-network providers and facilities directly. 
  • Generally, your health plan must: 

   o Cover emergency services without requiring you to get approval for services in advance (also known as “prior authorization”). 

   o Cover emergency services by out of network providers. 

   o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits. 

   o Count any amount you pay for emergency services or out of network services toward your in-network deductible and out-of-pocket limit. 

If you think you’ve been wrongly billed, contact the federal phone number for information and complaints at 1-800-985-3059. 

Visit for more information about your rights under federal law.