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Download Forms and
Instructions
Before Your Appointment
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This page contains important forms unique to Richmond
Eye Associates that can be downloaded for informational purposes, or for printing and filling out
prior to an eye examination.
Pre-examination Forms:
Download the Richmond Eye Associates Form Packet Here
to
print and fill out before
your visit. This packet includes the following required forms:
Patient Information form, Medical Services Contract, Medical Information
Forms, Privacy Summary, Privacy Acknowledgement Form, and the Medicare
Beneficiary Agreement.
 (To
print these forms, the Adobe Acrobat Reader is Required. If you do
not have this program it is a
Free Download )
Alternatively, you can download and print
out the form pages individually below:
-
Patient Information Form - general information about
your name, address, etc. This needs to be updated on an annual basis.
-
Medical Services Contract -
a general
medical services form allowing us to treat you, which also needs to be signed on an
annual basis.
-
Medical Information Form -
a form with questions about the health of your eyes, and your general health.
This should be filled out if you are a new patient, or if there are significant changes in your medical condition.
-
Notice of Privacy Practices -
this
document discusses how medical information about you may be used and
disclosed, and how you can gain access to this information.
Read a brief summary about Richmond Eye Associates Privacy Policy at
Patient Privacy Notice Summary.
-
Notice of Privacy Practices Written Acknowledgement Form -
this
form states that you have been provided a copy of the Richmond Eye Associates Notice of Privacy Practices.
You can also create a list of names of individuals that you authorize Richmond Eye Associates to release your personal health
information to (including verbal and written discussion). This list could include other physicians
or family members.
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Medicare Beneficiary Agreement -
this form states that Refraction
is a non-covered service by Medicare, but that the service can be billed
for by Richmond Eye Associates. This
agreement needs to be signed on an annual basis.
-
Optional: Laser Vision Correction Screening Form -
a form with specific
questions regarding being a candidate for Laser Vision Correction (Lasik), if
you are having a Refractive Surgery Screening Evaluation.
You can download and print directions to each Richmond Eye Associates
Office Location on the Office Location Page (which
also includes maps), or print directions here:
Please also check your insurance to determine if you need a referral from
your primary care physician before your eye examination. You can check a list of
Insurances that we accept.
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