OFFICE FORMS
Office Forms
Download these forms as you care to, completion prior to presentation may you save time in Office. Some questions apply, some may not apply, some are easier to answer than others – we can go over them later. The questions about being blurry mean with either your glasses on or your contact lenses on. Leave questions blank should you either be confused by them or object to them........I'll understand. It is not absolutely necessary that you complete all forms or download any forms. It seems a reasonable idea that you would not enter your Social Security number on any form prior to your coming into the Office.
1. General Exam form - you will need this copy.
2. Medical History Questionnaire - two pages, it would be best to complete this form. It was mostly invented by The Government and is requested by Medicare.
3. HIPPA Privacy forms, total 4 pages.Completion is optional.We will respect your Privacy the same way should you fill out these forms or choose to ignore them.None of your Information will ever be “On-Line” in our computer.
4. Life-time Signature Forms are best completed in Office.Your completing this form and carrying it around with you could be a problem if you later lost it.It will take less than one minute to complete in Office.A standard formality form of virtually all Insurance.
5. Advance Beneficiary Notice form.This is paperwork that says Medicare does not pay for everything, which most everyone already knows.A standard Medicare formality form.
6. Records Release form.A necessary form for requesting your files be sent to my Office from a different Doctor or other Clinic.
Print out these forms by clicking on the icon to download
General Exam Pg. 2 has to be printed and brougt with you.
Print out these forms by clicking on the icon to download
Please print and sign HIPPA pg, 1-4, and bring them to the office with you.
Please print, fill out, and sign the Life-time signature form, the advance Beneficiary Form, and the Records Release Form and bring them to the office with you.
Contact Information
Dr. Stanley J. Hallock
5460 Curry Ford Rd
Orlando, FL 32812-8567
Phone:
After Hours/Emergency:
(407) 963-9633
Email: eyerace@aol.com
Insurance