Patient Forms

Patient Forms

Please fill out the following forms and sign consents prior to your visit (all forms are HIPAA compliant):

What to bring

Please bring your latest glasses with you: sunglasses, computer glasses, distance glasses, reading or progressives. Also, bring with you old contact lens boxes that have your prescription printed on them or a written prescription copy. Lastly, bring your medical insurance card in case the doctor needs to refer for a certain condition.


Eyes of East Sacramento​​​​​​​ Sac has 3 designated parking spots in the back of our building. You can find the entrance to the parking lot behind

Birkland on 33rd St.

Notice of Privacy Policy

Doctors have always protected the confidentiality of health information. Today, state and federal laws also attempt to ensure the confidentiality of this sensitive information. The federal government has published regulations designed to protect the privacy of your health information. The “privacy rule” protects health information that is maintained by health care providers, hospitals and health plans. Doctors have to comply with the privacy rule’s standards for protecting the confidentiality of your health care information. The new regulation protects virtually all patients regardless of where they live or where they received their health care. Every time you see your doctor, are admitted to the hospital, fill a prescription, or send a claim to a health plan, your doctor, the hospital, or other health care provider will need to consider the privacy rule. All health information including paper records, oral communications, and electronic formats (such as E-mail) are protected by the privacy rule. The privacy rule also provides you certain rights, such as the right to have access to your medical records. However, there are exceptions: these rights are not absolute. We also take precautions in our office to safeguard your health information such as training our employees and employing security measures. Please feel free to ask your doctor about exercising your rights or how your health information is protected in our office. The Notice of Private Practices explains our privacy practices. It is available for you to review or request a copy for your records. It contains very important information about how your confidential health information is handled by our office. It also describes how you can exercise your rights with regard to your protected health information. You will be asked by staff to sign the Notice of Privacy Practices once you’ve checked in for your appointment.

Payment Options

At Eyes of East Sacramento Sacramento, our goal is to promote good eye health and enable you to have the clearest vision possible. We accept several types of vision insurance, Care Credit, cash, checks, and most credit cards. If you require a breakdown of costs, please let us know.

We will work directly with you and your vision insurer to submit claims regarding your vision care. We strive to ensure that you understand your insurance coverage and will answer any questions you may have regarding your benefits. Many current vision plans are designed to cover most of the basic vision-related costs, but not all costs associated with eye care. Most plans often require a co-payment for an office appointment as well as additional costs that are covered by the insured patient.

Contact our office at (916) 915-0500​​​​​​​ to find out if your insurance provider is accepted in our office or for more information about your vision coverage.

Flexible Spending Accounts Many employers are offering a Flexible Spending Account (FSA) options to employees. Sometimes these are referred to as cafeteria plans and are elective, supplemental insurance savings plans. These plans are designed to let you save money in an account, pre-tax, to pay for additional medical expenses such as eye exams, glasses, contacts, and often laser vision surgery. Check with the benefits administrator at your work to see if you are eligible for this program. FSAs can typically be used in conjunction with any vision insurance plan to offset any out-of-pocket costs on your behalf.

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