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Located on W. Drake Rd. in Ft. Collins West of Colorado State University Veterinary Teaching Hospital

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Home » Contact Us » Patient Welcome Form

Patient Welcome Form

  • Date Format: MM slash DD slash YYYY
  • for appointment reminders and notification of glasses and contacts
  • Health Insurance Portability and Accountability Act-HIPAA


  • Health Insurance Portability and Accountability Act-HIPAA
    We respect the legal obligation to keep your health information private. The most common reason why we use or disclose your health information is for treatment, payment, or health care operations. If you would like a copy of our Notice of Privacy Practice please let the front desk know. By signing below it means that you are aware of our privacy practices and that you have been given the opportunity to obtain a copy of our policy.
  • Date Format: MM slash DD slash YYYY
  • Payment Information


  • Payment Information
    Payment is expected at the time services are rendered. Accounts left unpaid after 120 days will automatically be turned over for collections along with a $35 service charge. I understand that I will receive a statement after 30 days if the insurance has not paid. I further understand that I am responsible for the total amount due or any amount unpaid by the insurance. Any denial or dispute of payment by my insurance company is my responsibility. If insurance is being billed by our office, this signature serves as your “signature on file”.
  • Date Format: MM slash DD slash YYYY
  • Authorization for Release of Information


  • Authorization for Release of Information
    Many of our patients allow family members to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to a family member, you must list the family/friend and sign below.
    I authorize Eyecare Associates to release my medical and/or billing information to the individuals listed below. I understand I have the right to revoke this authorization at any time and that I have the right to inspect or receive a copy of the PHI to be disclosed.
  • Date Format: MM slash DD slash YYYY
  • VISION HISTORY

  • Date Format: MM slash DD slash YYYY
  • Please list
  • SelfFamily Member(s)
    Glaucoma
    Macular Degeneration
    Cataracts
    Diabetic Eye Disease
    Retinal Detachments
    Keratoconus
    Amblyopia
    Eye Turns
    Eye Surgeries
    Eye Allergies
    Eye Injuries
    Eye Infections
  • HEALTH HISTORY

  • Are you currently pregnant or nursing?
  • SelfFamily Member(s)
    Digestive System
    Blood / Lymph
    Ear / Nose / Throat
    Allergies / Immune system
    Skin
    Mental / Psychiatric
    Musculoskeletal (arthritis, joint pain, etc.)
    Respiratory (asthma, emphysema, etc.)
    Nervous System (headaches, MS, seizures, etc.)
    Endocrine (thyroid, diabetes, etc.)
    Cardiovascular (cholesterol, high blood pressure, etc.)
    Genitourinary (kidney, bladder, etc.)
  • Thank you and welcome to our practice!

As of Tuesday evening, March 17th, the CDC has recommended that all routine eye care be deferred until further notice, in order to slow the transmission of COVID-19 through our community. We will follow their recommendations and close our office to regular eye exams until further notice.

Please be assured that we are still available to triage all urgent and emergent issues as well as help you with routine matters during this challenging time.

What does this mean?

1) If you are scheduled for an annual eye examination our office will contact you to reschedule
2) If you need to replace glasses or contact lenses and need an extension on your prescription, please contact us and we will assist you in obtaining some until you can come in for a visit.
3) If you are running out of medication please contact us and we can transmit a refill electronically to your pharmacy.
4) If you have an ocular emergency we are, as always, available to help you at any time. Call us at 970-221-4811.
5) If you have an issue that cannot wait for an office visit, contact us and we will schedule a FaceTime, Skype or telephone appointment with one of our doctors. Medicare has temporarily relaxed its telehealth rules to allow this type of communication during the pandemic crisis. Other insurers may follow suit and allow for reimbursement of virtual care costs. The consultation must be initiated at your request.
6) During this period of social distancing and quarantine, we must all do our part by restricting activities outside the home except for getting medical care. Do not go to work, school, or public areas. Avoid using public transportation, ride-sharing, or taxis.
7) Please remember that 80% of COVID-19 cases are mild and resolve within a week. However, if you feel your symptoms are worsening, call ahead before visiting your doctor’s office or emergency department and tell them you have or may have COVID-19. This will help the office protect themselves and other patients.

The CDC has many wonderful resources. Arming yourself and your family with clear information will help you avoid undue stress.https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html https://www.cdc.gov/coronavirus/2019-ncov/prepare/managing-stress-anxiety.html

We have asked our staff to stay home until further notice to protect them, our patients, our city, our nation, and our planet. Despite the financial and emotional hardships this will cause, we ask every one of you to do the same.

Together we will weather this storm.

With sincerest wishes for your continued good health, we remain at your service,

Eyecare Associates