Patient Forms

Direct Eye Care

Click on any of the pdf icons below to open the corresponding forms:

Notice of Privacy Practices
A part of the Health Insurance Portability and Accountability Act (HIPAA), this notification explains your privacy rights as a patient.

Release of Medical Information

Form used to transfer your medical records from another office to EyeCare for You.

Advance Beneficiary Notice of Noncoverage (Medicare Patients Only)

Form explains any fees that are not covered by Medicare.  The fees are based on the services being rendered to each patient. Every Medicare patient receives this form during check-in.

Amsler Grid Test

A tool that Dr. Ramsey uses to help detect vision problems resulting from damage to the macula (the central part of the back of the eye) or the optic nerve.

Schedule an appointment today by calling 919.249.2020 or book online with the button below.