Forms
Click on any of the forms listed below for a printable copy. Maps and directions to any of our locations can be found in the "Offices" section of this website.
NEW PATIENTS
Thank you for choosing The Retina Institute for your eye care needs.
For your convenience, you can access and download some of the paperwork necessary for your appointment. Prior to seeing your physician, you will be required to complete the following forms:
Patient Registration Form
Medical History Form
Authorization of Communication to Designee
Payment Policy & Authorization of Benefits
Upon your arrival at our office, you will also be offered a copy of our Notice of Privacy Practices. We are required by law to inform you how your health information may be used and disclosed. If you wish, you can review this policy now by clicking the highlighted link.
Acknowledgement of Privacy Practices Received
Once again, we thank you for choosing The Retina Institute.
NOTICE TO PATIENTS
Please be aware there are fees associated with completion of some forms.
Medical Records to patients - $10.00
(Payable prior to processing and requires a signed release form.)
Medical Records to physicians - No Charge
(Requires a signed release form.)
FMLA Forms - $25.00
(No charge to surgery patients.)
Attending Physician Statement - $25.00
(No charge to surgery patients.)
Disability Form - $25.00
(No charge to surgery patients.)
Disabled Parking Placard/Plates - No Charge