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Office Visit Form (English)

If you already have an appointment with a doctor at Ophthalmology Associates please read, complete and submit the following forms. This will expedite your check-in for your upcoming appointment.  These forms are required twice a year, so, it is only necessary to complete them every 6 months after your first submission.

If you want 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 here 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:
Ophthalmology Associates
1201 Summit Avenue
Fort Worth, TX 76102
Attn: My Le, Privacy Officer



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