PATIENT Registration


Please arrive 15 minutes prior to your appointment time.

*Remember to bring your ID, current medical insurance card, your glasses and a list of current medications.

We look forward to seeing you at your up coming appointment.

If you would prefer to fill out the forms, the printable pdf documents are located below the online form. Please fax them to 512-868-3907 or email them to info@clarityeye.net prior to your appointment.

 

Demographic Information

Person NOT living with you.

Insurance Information

Please fill out information correctly and attach an image of the front and back of your insurance cards.
If self pay, type self pay.
If self pay, type self pay.
Drop your file here or click here to upload.
Drop your file here or click here to upload.
Drop your file here or click here to upload.
Drop your file here or click here to upload.
(Initials required) *You have the right to terminate this authorization at any time by submitting a written request to our Privacy Manager. Termination of this authorization will be effective upon written notice, except where a disclosure has already been made based on prior authorization. *The practice places no condition to sign this authorization on the delivery of healthcare or treatment. We have no control over the person(s) you have listed to receive your protected health information. Therefore, your protected health information disclosed under this authorization may no longer be protected by the requirements of the Privacy Rule, and will no longer be the responsibility of the practice.

Payment Agreement

By initialing here, I agree that I have received and read the Clarity Eye Center Payment Agreement. Privacy & Payment Agreement Form (English) Formulario de Prividad y Acuerdo de Pago (Español)

Notice of Privacy Practices

Don't forget to press SUBMIT below to complete the form. Thank you from Clarity Eye Center.

 

After submitting your new patient paperwork, please fill out the COVID screening 1-2 days prior to your appointment. Thank you.

COVID Screening Page

 


Printable Registration Forms – you will need to print, fill out, and bring in the Registration Form, Privacy & Payment Form, Notice of Privacy Practices and Disclosure Authorization. Thank you.

 

Registration Form (English)

Formulario de Inscripcion (Español)

Privacy & Payment Agreement Form (English)

Formulario de Prividad y Acuerdo de Pago (Español)

Notice of Privacy Practices (English)

Notificación de prácticas de privacidad (Español)

Disclosure Authorization (English)

Divulgación a amigos, cuidadores y / o miembros de la familia (Español)

Copyright © Clarity Eye Center | Notice of Privacy Practices (English) | Notificación de prácticas de privacidad (Español)