Pre-Registration Form (English) for Scheduled Appointment
(To schedule an appointment click Request An Appointment and we will contact you.)
If you have an upcoming appointment with a doctor at Ophthalmology Associates please complete the form below and click the SUBMIT BUTTON at the very bottom of the last form. Errors will appear in red or with an * and must be completed then click the SUBMIT button again.
PATIENT NOTICE OF PRIVACY PRACTICES
The protection of your health information is important to us at Ophthalmology Associates. Please read our Notice of Privacy Practices: https://www.fortworth2020.com/wp-content/uploads/2019/02/Notice-of-Privacy-Practices-English-and-Spanish-Combined.pdf . 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 at the bottom of your submission. If you have any questions about the Notice of Privacy Practices, please notify an Ophthalmology Associates physician or staff member. Your submission of the forms below acknowledges that you have been provided the opportunity to read the Notice of Privacy Practices at Ophthalmology Associates.
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