Office Visit Form (English)
COVID-19 UPDATE – YOU MUST BRING YOUR OWN MASK AND WEAR IT WHILE IN THE BUILDING AND DURING YOUR APPOINTMENT UNTIL FURTHER NOTICE. Please see link below for our full update to our patients.
If you have an upcoming appointment with a doctor at Ophthalmology Associates please read, complete and submit the following forms. This will expedite your check-in on the day of your visit.
It is only necessary to complete these forms once a year UNLESS YOU HAVE MOVED, CHANGED INSURANCE OR HAD CHANGES IN YOUR MEDICATIONS OR MEDICAL HISTORY .
Our appointment reminders are automated so, if you have follow-up appointments during the year, you may receive this link again but you do not need to fill this out each time UNLESS YOU HAVE HAD ANY CHANGES.
Also, please remember to click the “SUBMIT BUTTON” at the very end.
All areas marked with an * are required.
If you receive an error message you may have missed an area with * so, please check through the form to identify this required information and then re-submit.
If you would like to schedule an appointment with a doctor at Ophthalmology Associates, please click the Request An Appointment button on the right and we will contact you.
Please remember to bring your insurance card and identification when you come for your appointment.
We appreciate your cooperation with this online registration and look forward to seeing you!
PATIENT NOTICE OF PRIVACY PRACTICES
The protection of your health information is important to us at Ophthalmology Associates. We have available to you a comprehensive version of our Notice of Privacy Practices if you wish to read it in its entirety. This notice can be found on our website in Patient Forms OR our front desk will give you a copy when you arrive for your visit. We ask that you acknowledge your opportunity to review a full copy of our Notice of Privacy Practices by signing the HIPPA and Acknowledgement form below. The delivery of your health care services will in no way be conditioned upon your signed acknowledgement. If you have any questions about the Notice of Privacy Practices, please notify an Ophthalmology Associates physician or staff member.
Please Read the Following
I have been provided the opportunity to read the Notice of Privacy Practices at Ophthalmology Associates.
I understand that Ophthalmology Associates is committed to treating and using protected health information about me responsibly. In using this information, this office will comply with all state and federal laws pertaining to your privacy rights, including the Privacy and Security protections provided to you by the Health Insurance Portability and Accountability Act (“HIPAA”).
I understand that my health record is the physical and legal property of Ophthalmology Associates, but the information belongs to me. I may have access to inspect, amend or obtain a copy of my health information. Costs will incur for copies of my records, and appointments must be made with the Privacy Officer to inspect, access, or amend my health information.
I understand that Ophthalmology Associates is required to maintain the privacy of my health information. Ophthalmology Associates will require my authorization to release my health information to outside sources with the exception of disclosures for purposes of Treatment, Payment, and Healthcare Operations. Your authorization will need to be in writing and it will be specific to the disclosure requested. Your authorization for use and disclosure of information, with the exceptions as referenced above, may be revoked in writing at any time. Please notify this office if you ever decide to revoke your consent.
If you believe that your privacy rights have been violated, you may submit a written complaint to our HIPAA Privacy Officer at the address below:
1201 Summit Avenue
Fort Worth, TX 76102
Attn: My Le, Privacy Officer