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.
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.
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
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.