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new patient forms eye clinic of austin

New Patient Forms

Below are our new patient forms for accepted insurance plans, patient registration, and Eye Clinic of Austin general information. A new patient is one who has not received any professional services from Eye Clinic of Austin within the past three years. Simply click the link and the PDF download should begin.

 

General Information

Notice about Disclosing Vision Insurance

Eye Clinic of Austin Accepted Insurance Plans

 

New Patient Registration Forms

The Eye Clinic of Austin uses a specialized practice management software program. We ask every patient to participate in maintaining the following:

  • Reviewing registration information
  • Providing current insurance cards (Required at every visit)
  • Providing drivers license or state issued identification (Required at every visit)
  • Allowing us to capture your photo for your account and chart (so the doctor can identify your electronic medical record)

Below are our registration forms. Patients are encouraged to complete and print these forms prior to arrival at our office. Be sure to bring your insurance card and identification with you.

New Patient Medical History

Patient Registration – Spanish

Patient Authorization Form

Authorization for Use or Disclosure of Medical Record Information

Tricare Patient Refraction Waiver (Tricare patients only)

Optomap Service – Elect or Decline (Routine vision exams only) Adult

Optomap Service – Elect or Decline (Routine vision exams only) Pediatric

 

Proof of Insurance

If you cannot provide proof of insurance on the day of your visit we will require you to read and agree by signing the following policy: Proof of Insurance Waiver

 

Managed Care Plans (HMO, MC, POS)

If you have a managed care insurance plan you may be required to provide our office with a referral and/or authorization to visit our doctors.  If you do not have a referral/authorization we will require you to read and agree by signing the following policy: Unauthorized Visit Waiver

 

Dry Eye & Refractive Surgery (LASIK/PRK) Forms

If you are coming in for a dry eye assessment or LASIK consultation, please download the respective form below, fill out, and bring in to your appointment.

Refractive Surgery Questionnaire

Dry Eye Questionnaire