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Visionary HIPAA and Office Payment Policy

REASON FOR VISIT:                       Please list CURRENT MEDICATIONS or               MEDICATION ALLERGIES:

__Yearly general eye exam              ___ allow Dr. to download med list                          __None

__Need more contacts                      __ none currently                                                    __Codeine  

__Blurry vision at distance                                                                                                __Contact lens solution

__Blurry vision at near                                                                                                      __Eye drops

__Pain or discomfort                                                                                                        __Novocain

__Eyestrain                                                                                                                      __Penicillin

__Dryness / Burning / Itching                                                                                           __Sulfa

__Urgent condition                                                                                                           __Other:



Health Insurance Portability and Accountability Act (HIPAA)

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you.  The notice contains a patient rights section describing your rights under the law.  You have the right to review our notice before signing this acknowledgement.  The Notice of Privacy Practices is available to view in our office.  If you would like to receive a copy of the notice, we are happy to email a copy to you.  They are also available on our website.  The terms of our notice may change.  If we change our notice, you may obtain a revised copy by contacting our office.

If you wish for persons other than those released under normal operations as indicated in the notice to receive confidential information that is now protected under this law you must release them in writing.  Parents or Guardians of minor children do not need to be released.

Please be aware that our staff has to follow federal law on information that we release by phone and we may at any time choose not to release information of any kind by phone if we feel that the person requesting information is not authorized or we feel the information may be too sensitive to release by phone.

By signing this form, you are acknowledging that Visionary Eye Care Professionals has made our Notice of Privacy Practices available to you for review and that we have offered you a personal copy.


Signature:  ____________________________________________________ Date:  ______________


Patient name (print):  _________________________________________________


Relationship to patient:  __________________________________________ 




By signing this form, you are acknowledging Visionary Eye Care Professionals’ Office Policy and Financial Agreement. Personal copies are available upon request. 


Signature:  _________________________________________________   Date:  _______________

Download this form here.