Patient Forms

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

Patient Registration Forms
Patient Registration Form
Patient Registration Form (Medicare)
Medical Records Release Forms
Medical Records Release - IN (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 plans, please call 804.285.0680 to confirm participation with your plan.

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.

Insurance

Dominion Eye Associates and its affiliate offices work with many insurance companies. Call your nearest Dominion Eye Associates today to determine the coverage of your insurance plan.

Financing

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

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

Patient Forms

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

Patient Registration Forms

Medical Records Release Forms

Notice of Privacy Practices/HIPAA

Insurance

Financing