Welcome to Eyebright Optometry!
6/15/21 Update per the department of health guidlines our healthcare clinic still requires masks for all individuals.
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.
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.
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.
For the safety of our patients we have new check-in procedures. Please look out for a seperate message with that information.
Please print name if signing for a minor.