Important Patient Forms & Documents

Authorization to Release Records to West Metro Ophthalmology

Use this form to authorize the release of your medical records to our practice. You may download, complete, and fax, mail, or bring the form with you to your appointment. Alternatively, call our office at (763) 546-8422 to have an electronic form emailed or texted to you that can be filled out and submitted electronically.

Authorization to Release Records from West Metro Ophthalmology

Use this form to authorize us to release your medical records to another provider. You may download, complete, and fax, mail, or bring the form with you to your appointment. Alternatively, call our office at (763) 546-8422 to have an electronic form emailed or texted to you that can be filled out and submitted electronically.

Authorization to Evaluate & Treat a Minor

Required for minors receiving treatment without a parent or guardian present. You may download, complete, and fax, mail, or bring the form with you to your appointment. Alternatively, call our office at (763) 546-8422 to have an electronic form emailed or texted to you that can be filled out and submitted electronically.

Request for Access to Protected Health Information

Use this form to request access to your protected health information. Please print the form, fill it out, and then fax, mail, or bring it to the clinic location nearest to you.

Minnesota Vision Report Form

Required by the Minnesota Department of Public Safety for individuals who have failed their vision screening exam during driver's license renewal. This form must be completed and signed by an eye care provider licensed in the State of Minnesota.

Please bring this form to your appointment, or download it using the button below. If the download does not work, visit the Minnesota Driver Compliance Requests and Forms page and look for "Vision Report (PS30338)".

Notice of Privacy Practices

Our HIPAA privacy practices and your rights regarding your health information. This document is for informational purposes only—there is nothing to fill out or bring to your appointment.

Nondiscrimination Notice

Information about our commitment to nondiscrimination in health care services. This document is for informational purposes only—there is nothing to fill out or bring to your appointment.

Proficiency of Language Assistance Services

Information about available language assistance services at our practice. This document is for informational purposes only—there is nothing to fill out or bring to your appointment.

No Surprise Billing Notice

Information about your rights and protections against surprise medical bills. This document is for informational purposes only—there is nothing to fill out or bring to your appointment.

Billing and Collection Policy

Details about our billing practices and collection procedures. This document is for informational purposes only—there is nothing to fill out or bring to your appointment.