Pre-Registration Form (English) for Scheduled Appointment
For UPCOMING APPOINTMENT – The form does not save until you hit the SUBMIT BUTTON so please have with you before starting your Medication List , your pharmacy name and phone number and the phone numbers of anyone you want to have access to your information. This information is different than the text you may have received to scan your ID and Insurance Card into our portal.
- The form is 3 forms in one. Your Medical History, your HIPAA (who can we talk to about your records), and your Patient Financial Policy.
- All questions should be answered as completely as possible.
- Questions with an asterick must be completed.
- There is one signature required on page 3. You can “sign” with your fingertip or by using the mouse as if it were a pen in your hand.
- After you have completed all pages and clicked the SUBMIT BUTTON at the very bottom of page 3, please wait to see a pop up that says “Thank you. Your form has been submitted”.
- If the form opens back up to a question or you see any red highlighted areas this indicates that you missed an area that was required. Find and complete any highlighted areas and then re-click the SUBMIT button at the very bottom. It is NOT necessary to re-sign.
- You will receive a message that thanks you for your registration when the submission is complete.
- The form does not save your work. It will time out if you leave the page OR take too long to complete the forms in one session. If you prefer, you can print the forms from our forms list to fill out by hand (HIPAA, Patient Financial and Medical History) and bring them with you for your appointment.
- Please remember to bring your insurance card and identification when you come for your appointment even though you may have submitted them through our portal.
- We appreciate your cooperation with this online registration and look forward to seeing you!
Patient Notice of Privacy Practices
The protection of your health information is important to us at Ophthalmology Associates. Please read our Notice of Privacy Practices: https://fortworth2020.com/wp-content/uploads/2019/02/Notice-of-Privacy-Practices-English-and-Spanish-Combined.pdf. We ask that you acknowledge your opportunity to review a full copy of our Notice of Privacy Practices by signing the HIPPA and Acknowledgement form at the bottom of your submission. If you have any questions about the Notice of Privacy Practices, please notify an Ophthalmology Associates physician or staff member. Your submission of the forms below acknowledges that you have been provided the opportunity to read the Notice of Privacy Practices at Ophthalmology Associates.
If you believe that your privacy rights have been violated, you may submit a written complaint to our HIPAA Privacy Officer at the address below:
1201 Summit Avenue
Fort Worth, TX 76102
Attn: My Le, Privacy Officer