New Patient Center

Online Forms

At Barrington Eye Care Center, P.C., we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment.

New Patient Health History Form – Required

Please complete this form as it lets us know the history and current state of your health. Let us know what questions, concerns, and goals your have regarding your eye health or vision on the form.

Patient Intake Form- English


Notice of HIPAA Privacy Practices

Dear Patient:
This notice is not meant to alarm you. Quite the opposite! It is our desire to communicate to you that we are taking seriously Federal law (HIPAA- Health Insurance Portability And Accountability Act) enacted to protect the confidentiality of your health information . We do not ever want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside our office.

Protecting Your Confidential Health Information is Important to us!
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully and if you have any questions about this notice, please contact us. This is effective until further notice.

Why do you have a privacy policy? Very good question!
The Federal government legally enforces the importance of the privacy of health information largely in response to the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of your health information. This has challenged us to review not only how your health information is used within our computers but also with the Internet, phone, faxes, copy machines, and charts. We believe this has been an important exercise for us because it has disciplined us to put in writing the policies and procedures we follow to protect your health information when we use it.

We want you to know about these policies and procedures which we developed to make sure your health information will not be shared with anyone who does not require it. Our office is subject to State and Federal law regarding the confidentiality of your health information and in keeping with these laws, we want you to understand our procedures and your rights as our valuable patient.

We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment, conducting health care operations, and as otherwise described in this notice.

How your HEALTH INFORMATION may be used To Provide Treatment
We will use your HEALTH INFORMATION within our office to provide you with medical care. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between health care providers and business office staff. In addition, we may share your health information with other health care personnel providing you treatment.

To Obtain Payment
We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with a similar commitment to the security of your health information.

To Conduct Health Care Operations
Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees.

It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.

In Patient Reminders
Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family.

These communications are an important part of our philo