Forms

The following forms are in PDF format. If you have Adobe Acrobat Reader you may open and print them. If you do not have Adobe Acrobat Reader, you can obtain a free copy by clicking on the image below and downloading it now.

Medical History Questionnaire:

This form is required for all new patients. Please print it out and complete it prior to your first visit. If you are unable to do so, please arrive 30 minutes in advance of your initial appointment to allow for sufficient time to complete it.

Patient Registration Form:

This form provides the patient’s basic information such as address, telephone number and insurance information. This form is required for all new patients and/or when a patient’s information changes.

Medical Records Release Form:

If you wish to have your previous medical records sent to Barenburg Eye Associates, just download and complete this form. Bring it to our offices and we will arrange the transfer.

Notice of Privacy Practices:

This form is required by the Health Information Portability and Accountability Act (HIPAA). If this is your first visit to our offices since March 1, 2003, you will be required to read this form and sign a copy for our files acknowledging that you are aware that we take your privacy very seriously.

Authorization For Release Of Identifying Health Information:

This form is not required prior to your visit with our offices, but it is highly recommended. It simply allows our offices to use specific but non-critical information to order frames and lenses and to bill your insurance company.

 

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