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New Patients Forms and Fees

Please bring insurance ID cards and photo ID with you for every visit, plus your current eyeglasses or contact lens prescription if available. ​
Patient Information and Eye History Forms
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Please download the forms and type in your answers as completely as possible. Then, save the forms and email them back to the office (contact@familyeyemed.com). You do NOT need to print out the forms. We will print out the forms for you to sign when you arrive for your exam.
Health Insurance Portability and Accountability Act (HIPAA) Form
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Please download the form and review Family Eye Medical Group's policies regarding your privacy. You do NOT need to print out the form and do NOT need to bring it with you to your next appointment. Just let the check-in desk know you have reviewed this information and do not need to be given a copy of this form.
Family Eye Medical Group Contact Lens Policy
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Contact lens services may be covered by vision plans but are not covered by medical insurance. If you would like to receive contact lens services during your eye exam, please review the form, but do NOT print it out and sign it. We will have it ready for you to sign when you arrive for your exam.
Family Eye Medical Group Request for Medical Records
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A signed medical request form is required to transfer medical records to or from our office. Please download the form and type in your answers as completely as possible before printing and signing the form. Then, you should send the form to your prior doctor if you want their records sent to us or return the form to our office by fax or email (contact@familyeyemed.com) if you want our medical records sent to your medical provider.
Family Eye Medical Group Fees
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Reschedule Missed Appointment - $25
Dictated Visit Summary - $10
DMV or School Forms - $10
Copy of Complete Medical Record - $20
FMLA or Disability Forms - $20
Social Security/Legal Documents - varies by statute
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For most documents, Family Eye will complete the request within one week (5 business days). Family Eye will replace eyeglass or contact lens prescriptions at no charge, but requires 48 hours advance notice to retrieve and verify the prescription.
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