Patient Forms

Patients may request miscellaneous forms to be filled out by our physicians by leaving them with our receptionist. Please allow 24 hours for the forms to be completed. 

• Misc forms - $50

Patient Medical Records Requests

• Most recent office visit is free of charge.
• $25 fee for up to 1 year of medical records.
• $50 fee for up to 3 years of medical records.
• $15 fee for each additional year.

• Medical Records Release Online Form

General Medical Records Request

It is imperative that we make sure there is a waiver on file requesting those records. Nothing can be released, not even to the employer, without this form signed by the patient.

• Insurance
  • $20 for the first 5 pages.
  • $0.50 for each additional page.
  • This fee should be charged to anyone requesting records other than a physician's office such as an attorney, disability departments, etc.
• Worker's Compensation
  • $10 for the first 20 pages.
  • $0.25 for each additional page.

Our Cancellation and No Show Policy

For the convenience of all of our valued patients and staff, we ask for a 48 hours' notice whenever you need to cancel an appointment. Getting cancellation information in advance allows us to adjust our staff schedule or notify another patient who might be waiting for an appointment opening.

CareCredit - Apply for Allied Eye

CareCredit is different from a regular credit card. Use it to pay for out-of-pocket expenses not covered by medical insurance, and special financing options are available that you may not be able to get with other cards. Pay for health, and wellness care at over 225,000 enrolled providers across the nation. Once you've applied, you can use it again and again at any location that accepts CareCredit.

Watch CareCredit's Informational video below: