Patient Info

Patient Forms

Thank you for choosing Dr. James Memmen and our ophthalmology staff for your eye care! This page will give you an idea of what to expect when you check in for your appointment.

 

New Patients

For your convenience, all of the forms you need to fill out for your first appointment with Dr. Memmen are listed below.
Please call us with any questions you may have.  You may either:

1.) Print the PDF below to fill them out at home. Then bring them with you to your first appointment.    OR…

2.) Fill them out on our secure page and click “Submit.” Your forms will automatically be sent directly to our staff through our private system.

Forms:

Health Information Disclosure Authorization – PDF
Health Information Disclosure Authorization – Online Form

  • This form gives permission to release your medical records from your previous eye care provider to Dr. Memmen.

Medication List and Medical History Questionnaire -PDF
Medication List and Medical History Questionnaire – Online Form

  • In order for our staff to give you the best patient care, they need to be fully informed of your medical history, and they need a complete list of the medication you are currently taking – no matter how trivial they may seem.

Notice of Privacy Practices – PDF

  • This form is the Notice of Privacy Practices stated under the Health Insurance Portability and Accountability Act of 1996 (“HIPPA”).  This form is simply a reference; you do not need to sign or fill anything out on this form.

In addition to the forms above, kindly bring the following to your appointment:

  • Current Insurance Card(s)
  • Driver’s License or State ID
  • Insurance Co-pay
  • Social Security Number

*Notice: Many insurance plans do NOT cover your refraction. You are then responsible for the $40.00 fee in addition to your co-pay at the time of your appointment. Please be sure to check with your insurance provider before your scheduled appointment.

*Notice: Please be aware that many insurance companies are now requiring authorization from your Primary Care Provider prior to being seen by a specialist.  Insurance companies will NOT cover the expenses of your appointment if you are required to obtain this authorization and do not.  It is your responsibility to provide a paper copy of this authorization on the day of your appointment; a verbal authorization will NOT be accepted by your insurance company.  We recommend that you call your insurance company to verify the requirements of your policy.
You may call the phone number on the back of your insurance card if you have any questions.

 

Returning Patients

Kindly bring the following to EVERY appointment:

  • Your most recent/updated insurance card(s)
  • Insurance Co-pay

*Notice: Many insurance plans do NOT cover your refraction. You are then responsible for the $40.00 fee in addition to your co-pay at the time of your appointment. Please be sure to check with your insurance provider before your scheduled appointment.

*Notice: Please be aware that many insurance companies are now requiring authorization from your Primary Care Provider prior to being seen by a specialist.  Insurance companies will NOT cover the expenses of your appointment if you are required to obtain this authorization and do not.  It is your responsibility to provide a paper copy of this authorization on the day of your appointment; a verbal authorization will NOT be accepted by your insurance company.  We recommend that you call your insurance company to verify the requirements of your policy.
You may call the phone number on the back of your insurance card if you have any questions.


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