• Welcome to Eyebright Optometry!

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  • Vision Insurance


  • If you are NOT the primary member on the plan please provide their information below.

  • In accordance with the Health Insurance Portability and Accountability Act (HIPAA) I read the copy of Eyebright Optometry Notice of Privacy (on the office website FORMS page) and understand I may request a copy of records. The Notice of Privacy Practices is subject to change. Update policies will be available at the front desk.

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  • I authorize the payment of health care benefits to this office. I understand I am responsible for payment of any charges not covered by insurance.

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  • I authorize any holder of medical information about me to be released and/ or request my medical information with other health care professionals for the purpose of consultation and referral as needed for my health care.

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  • For the safety of our patients we have new check-in procedures. Please visit our website http://www.eyebright2020.com/important-covid-19-office-updates for information.

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  • Please print name if signing for a minor.

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