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Patient Forms

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Patient Forms

To make your visit at Chicopee Eyecare go as smoothly as possible, it would be helpful to bring the following information with you:

  • Patient and Insurance Information Form - download here.
  • Authorization to Release Information Form.
  • Refraction Policy Form - download here.
  • Patient Financial Agreement Form - download here.
  • Hippa form - download here.
  • Your glasses and contact lens prescription if possible.

If you have been sent to us by another office, please let us know so that we can promptly send a report to your doctor. Sometimes repeated office visits will require the patient to obtain a referral from their primary care provider so please call your doctor or insurance company to help us comply with their rules.