alarm-ringing ambulance angle2 archive arrow-down arrow-left arrow-right arrow-up at-sign baby baby2 bag binoculars book-open book2 bookmark2 bubble calendar-check calendar-empty camera2 cart chart-growth check chevron-down chevron-left chevron-right chevron-up circle-minus circle city clapboard-play clipboard-empty clipboard-text clock clock2 cloud-download cloud-windy cloud clubs cog cross crown cube youtube diamond4 diamonds drop-crossed drop2 earth ellipsis envelope-open envelope exclamation eye-dropper eye facebook file-empty fire flag2 flare foursquare gift glasses google graph hammer-wrench heart-pulse heart home instagram joystick lamp layers lifebuoy link linkedin list lock magic-wand map-marker map medal-empty menu microscope minus moon mustache-glasses paper-plane paperclip papers pen pencil pie-chart pinterest plus-circle plus power printer pushpin question rain reading receipt recycle reminder sad shield-check smartphone smile soccer spades speed-medium spotlights star-empty star-half star store sun-glasses sun tag telephone thumbs-down thumbs-up tree tumblr twitter tiktok wechat user users wheelchair write yelp youtube

Patient Forms

eForms and downloadable patient forms that you can securely fill out online or print and fill out before your next visit to Shawnee Vision Source.

For your convenience, we have created the following electronic and downloadable forms to save you time at you next appointment with our office.

Electronic Forms

Online forms will cover most of your patient information needed however you will still need to provide the following in office:

    • All medical and vision insurance cards
    • State or federally issued photo id
    • Full social security numbers for patient, guarantor and primary insured
    • Signatures for financial responsibility and HIPAA forms

 

  • Patient Form [eForm]
    • This form provides patient and insurance information needed for your exam and services. It also authorizes us to file your insurance as well as reviews the required patient responsibility.

 


 

Downloadable Forms

  • Click on the yellow hyperlinks below to download forms
  • You will need AdobeReader® to download and complete the forms. Click here to download.
  • Download the required form(s). Print out the form(s) and complete the required information.
  • Fax your printed and completed form(s) to our office or bring them with you to your appointment.
  • When returning forms please attach the following:
    • All medical and vision insurance cards
    • State or federally issued photo id of patient or legal guardian if patient is a minor
    • Full social security numbers for patient, guarantor and insurance policyholders
  • Patient Form [Printable]
    • This form provides patient and insurance information needed for your exam and services. It also authorizes us to file your insurance as well as reviews the required patient responsibility.
  • Release of Information Authorization [Printable]
    • Print and fill out this form is you are either wanting us to obtain records from another office for you or wanting us to send your records to another provider.