Please print and fill out these forms and bring them along to your first appointment. At this time, forms cannot be filled out electronically. If you fill out this form online, we will not receive the information.
Disclosure of Protected Health Information
Use this form to give permission to a spouse, adult son or daughter, sibling, or any other person you wish to have access to your medical record. This permission would include questions about diagnoses, medications, procedures, or any other information from your chart, as well as insurance and billing information. Instructions for filling out this form will print along with the form. This form is required for anyone over the age of 18, regardless of continued coverage under a parent's insurance plan.
Release of Information Request
If you have a history of eye problems, have had cataract surgery or another procedure in the past, or if you are moving and need your records transfered to a new doctor, please use this form. Be sure to circle whether records are to be sent to us by another doctor (circle "Release From") or whether you need your records from our practice to be sent to a new doctor (circle "Release To").
Please note, if you have a basic history with no underlying medical diagnoses, we do not require your prior records. We also do not require records from your family physician.
These are our current office Policies and Procedures if you require a copy for your personal records.
These are our current office Privacy Practices if you require a copy for your personal records.
THE GREENVIEW PAVILION
3000 CG ZINN ROAD
THORNDALE, PA 19372
P : 610-384-9100
F : 610-384-3937
EYE DOCTORS OF CHESTER COUNTY
1175 Lancaster Avenue
BERWYN, PA 19312
P : 610-384-9100
F : 610-384-3937