Patient Forms

In order to properly care for you and for our clinic to remain compliant with clinical standards of care, with federal regulations, and with health insurance protocols, Eyes On Main must obtain some information from you. Below are forms you may download. It's helpful to complete these forms (black ink only) and bring the completed forms to our clinic on the day of your appointment. If you are unable to fill out the forms before your visit, please arrive 5-10 minutes prior to your appointment.

Practice Privacy Statement
The Federal Health Information Portability and Accountability Act of 1996 (HIPAA) requires that our clinic inform you of how we use, disclose and maintain the privacy of all the information we collect about you as our patient. We ask that you read this document, acknowledge that you have read it by signing the document and bring the form to your appointment.

Authorization for use or Discloser of Protection Health Information (Release of Patient Records)
This form is to be used if you would like your past provider to release your medical and/or prescription information to Eyes On Main, or in the event that you would like Eyes On Main to release your medical record and/or prescription information to another provider.