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 forms below. This may take a few minutes and you will need to have your medication and insurance cards handy to complete your medical history. All questions should be answered as completely as possible. Questions with an asterick must be completed. Signatures (there are 3 areas for signature) must be completed. You can “sign” these with your fingertip or by using the mouse as if you were using a pen in your hand. When the form is completed click the SUBMIT BUTTON at the very bottom of the last form. If the form opens back up to a question or you see any red highlighted areas this indicates that the submission is incomplete. Find and complete any highlighted areas and then re-click the SUBMIT button at the very bottom. You will receive a message that thanks you for your registration when the submission is complete. The form does not save your work. It will time out if you leave so please be sure to complete the forms in one session or print the forms from our forms list to fill out by hand. (HIPAA, Patient Financial and Medical History) 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. 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