Patient Forms

Approved Participants of Care

The Approved Participants of Care form gives L.O. Eye Care physicians and staff the authorization to discuss a patient's care with family members and/or other designated people on the list. Download the Form.

Medical Records Policy and HIPAA Release Form

Patients, who wish to receive a copy of their medical records, should print and sign the Medical Records Policy and HIPAA Release Form. This form explains L.O. Eye Care’s policies and pricing for the release of medical records. Completed forms can be faxed to: 517.337.1779. Download the Form.

Notice of Privacy

The Notice of Privacy describes how medical information may be used and disclosed, as well as how patients can receive access to it. Download the Form.

Personal Health History

The Personal Health History form provides L.O. Eye Care with up-to-date information about a patient’s current health status, medications and family history. Forms may be completed prior to your appointment and can be brought to the appointment or faxed to 517.337.1779. Download the Form.

Permission to Treat

The Permission to Treat form must be completed by the parent or legal guardian of minor patients who are established with the practice in order for an unaccompanied minor patient to be treated. Minor patients who are new to the practice must be accompanied by a parent or legal guardian for their first visit. Download the Form.

Signature on File

The Signature on File form is the form that patients are asked to sign once at check-in. This form gives L.O. Eye Care authorization to bill the patient’s insurance company and insures the patient’s responsibility for co-payments, deductibles, etc. Download the Form.