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Plaza 10 Drive Location

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Eye Centers of Southeast Texas
Call us at 409-833-0444

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Patient Information Form

Please download our New Patient Form and print it out with the information requested so that you may save time during check-in.

All new patients and existing patients that have not been seen in our office in the past year please download and print the following forms located below:  Patient Information, Insurance Information, Consent, Patient History, Assignment of Benefits, and Release of Billing and Medical Information over the Phone.  This will make check-in for your exam easier.

[ Last Updated: 2011-07-26 10:06:35]

Insurance Information

Please download the Insurance Information form and print it out with the information requested so that you may save time during check-in.

[ Last Updated: 2011-07-26 06:58:41]

Consent Form

Please download the Informed Consent form and print it out with the information requested so that you may save time during check-in.

[ Last Updated: 2011-07-26 06:59:11]

Patient History Form

Please download and print out the Patient History Form and fill out the requested information to save time upon check-in.

[ Last Updated: 2009-11-11 10:06:10]

Assignment of Benefits Form

Please download and print the Assignment of Benefits form and bring it with you to your appointment signed to expedite your check-in.

[ Last Updated: 2011-07-26 08:04:26]

Release Form for Billing and Medical Information over the Telephone

Please download the Authorization to Release Medical Information form and print it out with the information requested so that you may save time during check-in.

[ Last Updated: 2011-07-26 07:42:19]

HIPAA Form / Notice of Privacy Practices

Please download the HIPAA Form / Notice of Privacy Practices form and print it out with the information requested so that you may save time during check-in.

[ Last Updated: 2011-07-26 06:30:42]

Authorization to Release Medical Records Information

Please download the Authorization to Release Medical Information form and print it out with the information requested so that you may save time during check-in.

[ Last Updated: 2011-07-26 06:30:54]