Patient Forms


City: State/ZipCode
Home Phone: Work Phone:
Other Phone: Alerts:
SSN Email
Birthday (mm/dd/yyyy) Occupation
Sex Male Female Employment Status Employed Full-Time Student Part-Time Student
Marital Status Employer/School Name
Billing Information Is The Billing Address the Same?

Home Phone:
Work Phone:

Vision Insurance

Insurance Information
If you have medical insurance, be sure to fill out the Medical Insurance tabs too. Most Vision Plans only cover refractions and routine, non-medical eye exams. Any exams involving medical problems such as eye injuries or infections, dry eye, cataracts, glaucoma, macular degeneration or monitoring for ocular side effects of chronic diseases such as diabetes and hypertension fall under your Medical Insurance coverage, not your Vision Plan.

Insurance Name:
Insurance ID:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
City: State: Zip:
Phone Number:

Medical Insurance

Insurance Information
Insurance Name:
Insurance ID:
Insurance Policy Group #:
Not Primary on Account: Not Primary
Primary on Account
Name:Last, First MI
Relationship to Insured:Spouse Child Other
Sex: Male Female
City: State: Zip:
Phone Number:

Medical History

Who may we thank for referring you? :
Medical conditions:
Oral Medications:
Primary Care Physician:
Last Eye Exam:
Eye History: Injuries, surgeries, major infection, other eye diseases:
Eye Medications:
Do you have current glasses:
Do you have sunglasses:
Ever Worn Contact Lenses:
Interested In Contact Lenses:
Interested in Laser Vision Correction:
Family Medical History:
Family Eye History:
Do you currently smoke cigarettes?:
Hobbies/special interests:


Within The Last 14 Days Have You Experienced Any Of The Following Symptoms:

Condition Yes No
Shortness Of Breath Or Difficulty Breathing
Repeated Shaking With Chills
Muscle Pain
Sore Throat
New Loss Of Taste Or Smell
Have You Traveled In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact
With Or Cared For Someone Diagnosed With COVID-19 In The Last 14 Days?
Have You Or A Member Of Your Household Had Close Contact With Or Cared
For Someone With A Presumptive Positive Case Of COVID-19 In The Last 14 Days?
Has Anyone In Your Household Been Asked Or Required To Quarantine Based On Contact
With A Person Who Has A Confirmed Or Presumptive Positive COVID-19 Test Result Or Diagnosis,
Or Have You Been Asked To Quarantine?

Retinal Imaging

At Columbia Vision Center, we constantly strive to integrate new technologies to enhance the level of care we offer our patients.

We are proud to offer retinal imaging, which is a method of taking a detailed picture of the inside of your eye. This procedure will assist in early detection of many disorders including glaucoma, diabetic retinopathy, macular degeneration, retinal detachments, and other vision-threatening conditions.

Although not covered by insurance, we highly recommend that all our patients have this baseline test.

Retinal Imaging $39

-A quick but detailed view of the back of the eye using digital photography which greatly enhances a doctor's manual notes. No dilation drops are needed in most cases.
-No blurred vision and light sensitivity for the patient since dilation is not usually required
-This image aids in the eye exam and is used for future comparison

I prefer retinal imaging today
I prefer dilation drops today
Discuss with Doctor

Eye Questionnaire
Please check all that apply:

Family history of macular degeneration
Issues with night vision
Issues with glare
Issues with light sensitivity
Issues with eye fatigue
Unclear vision
Itchy eyes
Dry eyes
Painful eyes
None of the above

Contact Lens Policy

Columbia Vision Center (CVC)

Contact Lens policy



It is our intention to provide our patients with the best possible contact lens services and materials available. Therefore, we are continually updating our lens inventory so that we can provide you with the latest products in contact lenses and solution. In order to maintain quality care, we strongly believe that providing our patients with all pertinent information regarding the procedures and fees relating to contact lenses before services are rendered is in the best interest of everyone.


We recommend a full eye exam yearly. The contact lens evaluation is NOT part of a full eye health exam. The tests performed during this evaluation are beyond those tests done during an eye health exam. These tests include checking for dry eyes and allergies,and taking other corneal measurements. The corneal-contact lens relationship is evaluated and the proper lens power is determined while wearing the lens.


Frequency of contact lens fittings:

1         Every 24 months or as recommended by the doctor, even if you are not having problems with your current contacts

2         If patient wishes to change to a different contact lens brand after the contact lens exam is completed

3         By Washington State Law, the evaluation must be done within 6 months of the full eye exam.


Fees for contact lens fitting:

1         $110 spherical contacts

2         $130 soft toric or rigid gas permeable

3         $150 bitoric, multifocal, multiple brands

4         $175-225 specialty contacts

5         $60 if we have tested for and dispensed samples but you then wish to abandon the evaluation process


Contacts lens follow-up:

1         If needed, the first follow-up should be within 30 days of contact lens dispense.

2         Your fitting period starts on your appointment date. *The contact lens evaluation fee will be collected on this day. Insurance benefits can be used when the actual contact lens supply is ordered.* All follow-up visits must be completed within 2 months of this date. You will be responsible for additional contact fitting fees (see schedule above) if more time is needed but cannot extend past 6 months of this initial fitting.



1         A contact lens prescription, by Washington State Law, does not exist until the doctor has seen the prescribed contact lenses on your eyes and deems the fit and vision to be adequate. Please be sure to wear the contacts into the follow-up appt.

2         By Washington State Law, the doctor can only give out prescriptions for contacts that have been evaluated on your eyes. No other brands or types may be substituted when writing this prescription.

3         It is possible for a separate medical eye condition to arise during the contact lens fitting period. If the doctor deems this to be the case, you are financially responsible for those office visits. We will do our best to assist in verifying benefits under your medical insurance, if applicable.

4         You have 2 weeks to pick up contacts after notification. After this time period, they will be returned to the manufacturer and you will be responsible for a restocking fee of $10.

5         Contact lenses are non-refundable at our discretion. Fees for services are non-refundable.

General Office Policy

General Office Policies for Columbia Vision Center


1)         Eye examinations may be billed through vision insurance or your medical insurance. If your exam reveals a medical diagnosis like cataracts or dry eye syndrome, it is more appropriate to bill your medical insurance for the exam. You are only responsible for your copay and special testing not covered by your insurance.

2)         If your insurance requires a referral from your primary care provider, you are responsible for securing this. If a referral is not obtained, you are financially responsible for the office visit charges.

3)         To avoid a cancellation fee, please give 24 hours notice so that we can accommodate other patients. The no-show fee is $50 for all appointment types.

4)         New glasses can take up to a month to get used to. If you are having a problem, please let us know no later than 2 months after you pick up your glasses so we can recheck your prescription. After this time, additional charges for the visit and remaking the glasses may apply. There are no refunds for custom prescription lenses, however, your lenses have a warranty. If you cannot adapt to the prescription lenses, we offer a 1-time change to another type of lens within 60 days. A complimentary prescription check by the doctor may be needed.

5)         If you change your mind regarding the frame you select after your custom lenses have been ordered for that frame, you can select a different frame under the following conditions:

a.         You would pay the difference in the new and old frame price. However, no refund will be given.

b.         There is a $100 charge for the cost of your new custom progressive, bifocal, or trifocal lenses or

c.         There is a $50 charge for the cost of your new custom single vision lenses.

6)         Our frames and lenses have a one year warranty against defects (some sale frames do not have a warranty). There is a $20 shipping and handling fee for each frame/part or pair of lenses, if needed.

7)         All sale frames are final sale. Clearance frames have no warranty.

8)         The return policy for non-prescription sunglasses, over-the-counter readers, and other optical accessories is 7 days for refund or exchange and must be in new condition.

9)         Please turn off phones during the eye exam. Thank you!

I have read and understand the General Office Policy for Columbia Vision Center.

Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully.


Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act ("HIPAA"), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.


For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization.

We must obtain your written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule. Your authorization should contain specific information regarding the information to be disclosed or used, the person(s) disclosing and receiving the information, expiration, right to revoke in writing, and other data. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.


You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer Dr. Jean Hua or email to

  • Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a "designated record set". A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.
  • Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.
  • Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
  • Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.
  • Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
  • Breach Notification. If there is a breach of your PHI, we will notify you of this breach, including what happened and what you can do to protect yourself. We will also notify the Secretary of Health and Human Services.
  • Right to a Copy of this Notice. You have the right to a copy of this notice.


If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer Dr. Jean Hua at Columbia Vision Center, (206) 382-6682, or in writing with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201. We will not retaliate against you for filing a complaint.

I have read and understand the Notice of Privacy Practices for Columbia Vision Center.

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