Patient Information

Patient Information

If you are a new patient to our Hoffman Estates ophthalmolgy office, the forms below will need to filled out when you arrive for your first appointment. Printing them, filling them out and bringing them with you will allow us to attend to your eye care needs more quickly than completing them on your arrival. Thank you and please call our office if you have any questions or need any assistance. 

New Patient Registration Form

Release of Medical Information

HIPAA Privacy Act


This web site uses files in Adobe Acrobat Portable Document Format (pdf) which require Adobe® Acrobat® Reader for viewing and printing. It is available to download free.

Payment Options

For your convenience, we accept cash, personal checks or money orders.
Most of our services are covered under your medical insurance and we typically bill your medical insurance for our services.  Payment is expected at the time services are performed for services not covered by medical insurance.


As a service to our patients, our practice accepts most insurance programs, including Medicare, PPO and non-managed care insurance plans.  We remind you that your specific policy is an agreement between you and your insurance company. Please keep in mind that you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. 

The fees charged for services rendered to those who are insured are the usual and customary fees charged to all our patients for similar services. Your policy may base its allowances on a fixed fee schedule, which may or may not coincide with our usual fees. You should be aware that different insurance companies vary greatly in the types of coverage available. Also, some companies take care of claims promptly while others delay payment for several months.