(703) 777-1299

Forms

Forms

We are pleased to welcome new patients to our practice!
All patients please review our Notice of Privacy Practices & the Optomap Description

For Non-Medicare Patients:

New patients

Welcome Form
HIPAA Form
Insurance and Communication Consent
Patient Disclosure and Emergency Contact Form
Electronic Medical Records Info.
Medical History Questionnaire
Optomap Retinal Consent

Returning Patients

Patient Confirmation of HIPAA
Insurance and Communication Consent
Electronic Medical Records Info.

Medicare Patients

New Patients

For your convenience you can print and complete the following Patient Information Forms to bring with you to your appointment:

Patient Confirmation of HIPAA
Insurance and Communication Consent
Patient Disclosure and Emergency Contact Form
Electronic Medical Records Info.
Medical History Questionnaire
Advance Beneficiary Notice of Non-coverage

Returning Patients

Patient Confirmation of HIPAA
Insurance and Communication Consent
Electronic Medical Records Info.
Advance Beneficiary Notice of Non-coverage

Insurance Information

We accept many eye insurance plans, including VSP. If we don’t take your insurance, we’ll help you file for reimbursement. Eye care services and products also qualify for your flexible spending account. There are so many plans available, please give us a call to discuss yours.

Practice Policies

Thank you for choosing Eyecare Center of Leesburg for your eye care. We strive to provide the best services and quality care possible. We also strive to have the same level of quality when billing for our services. This guide will serve to assist in getting your services paid.