800-331-6634

Forms

Appointment Information & Forms

If you are a new patient to our practice and have an appointment scheduled, you may print out the registration form below and complete it prior to the day of your appointment.

It is very important that we receive all of the information requested so we can provide the highest level of care for you. In addition, this will allow us to properly communicate with your referring doctor and primary care doctor. Please keep us updated on your insurance information as well so that our billing department can successfully complete all the insurance billing and precertification procedures in a timely fashion.

Thank you for your cooperation in filling out these forms.

About your office visit:

  • Your eyes will be dilated for the examination.
  • You will need someone to drive you.
  • Your visit may last between 1 and 3 hours depending on the type of evaluation.
  • Diabetic patients are asked to bring a snack in case the appointment runs into their lunch or dinner time.

Please bring the following with you on the day of your appointment:

  • The completed registration forms
  • A list of all medications and eye drops that you are currently taking
  • Any contact lenses or glasses that you currently wear
  • Your current insurance cards
  • Co-pays for specialists as noted on your insurance card
  • Referrals from your primary care physician if your insurance requires a referral to see a specialist. (NOTE: Without a proper referral, payment will be due at the time of the office visit.)
  • A valid picture identification card

NOTE: Review your insurance for deductible or coinsurance amounts that may apply at the time services are rendered.  If we do not participate with your insurance, payment will be collected at the time of the office visit.

Please feel free to contact us Toll Free at 800-331-6634 with any questions.

Requesting Medical Records

You can download and print our Medical Record Release form or obtain a form from the front desk at any Mid Atlantic Retina location.  Your records will be sent to you upon receipt of the signed Medical Record Release form.

You can request records from Mid Atlantic Retina three ways:

  • Mail the completed form to your Mid Atlantic Retina office.
  • Fax the completed form to your Mid Atlantic Retina office.
  • Bring in the completed form to your Mid Atlantic Retina office.

Cost

You will receive a call from our office indicating the cost to copy your records. Mid Atlantic Retina charges only the state regulated charge for copies of your medical record.

Processing Time

Please allow up to 30 days to process your request.

Authorization Signature for Your Records Release

By law, the following authorized people are able to sign for the release of your health information:

  • Yourself  (not your spouse)
  • A parent (for patients younger than 18 years of age)
  • Legal guardian (guardianship documentation is required)
  • Power of attorney if patient is unable to sign (legal documentation is required)
  • Estate representative for a deceased patient (estate documentation is required)

Please feel free to contact us Toll Free at 800-331-6634 with any questions.