Patient Forms

Please browse through our patient information listed below - including patient registration forms, medical record release forms, insurance information, and CareCredit financing.

Patient Registration Forms
Commercial Packet
Medicare Packet
Minor Patients Consent Form
Medical Records Release Forms
Patient Access to Protected Health Information (Use this form when you are requesting that another provider send us your records)
Medical Records Release - OUT (Use this release form when you are requesting that we send records to another provider)
Notice of Privacy Practices/HIPAA
Click Here to view.

We participate with most insurance, please call 804.285.0680 to confirm participation with your plan.

Insurance

Dominion Eye Associates and its affiliate offices participate with many insurance companies. Call your nearest Dominion Eye Associates today and confirm your coverage.

Financing

At all of our locations, we gladly accept Medicare and participate with most insurances. As a courtesy to our patients, we will file both your primary and secondary insurance forms.

Dominion Eye Associates accepts CareCredit for payment for services – for more information or to apply online, please visit CareCredit.com.

*CareCredit terms and conditions may apply.

For any and all billing, statement, or balance due inquiries only, please contact 877.969.0392. All other clinical related questions should go directly through your physician’s office line.

Patient Forms

Please browse through our patient information listed below - including patient registration forms, medical record release forms, insurance information, and CareCredit financing.

Patient Registration Forms

Medical Records Release Forms

Notice of Privacy Practices/HIPAA

Insurance

Financing