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HIPAA Insurance Form

Patient Consent for Use and Disclosure of Protected Health Information

  • I hereby give my consent for Blue Ridge Eye Care Associates & Family Vision Care to use and disclose protected health information under the Health Insurance Portability Act (HIPAA) to carry out treatment, payment and healthcare operations. Blue Ridge Eye Care Associates & Family Vision Care Notice of Privacy provides adequate notice and disclosures to protect your health information.

    With this consent, Blue Ridge Eye Care Associates & Family Vision Care, may call my or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out healthcare operations, such as appointment reminders, patient statements, insurance items and any calls pertaining to my clinical care, including laboratory/imaging results among others.

    By signing this form, I am consenting to Blue Ridge Eye Care Associates & Family Vision Care use and disclosure of my healthcare information to carry out any healthcare operations. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Blue Ridge Eye Care Associates & Family Vision Care, may decline to provide treatment.

Our Locations

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Hours of Operation

Our Regular Schedule

Blue Ridge Eye Care

Monday:

8:00 am-6:00 pm

Tuesday:

8:00 am-6:00 pm

Wednesday:

8:00 am-5:00 pm

Thursday:

8:00 am-5:00 pm

Friday:

8:00 am-5:00 pm

Saturday:

By Appointment Only

Sunday:

Closed

Family Vision Care

Monday:

8:00 am-1:00 pm

2:00 pm-5:00 pm

Tuesday:

8:00 AM-1:00 pm

2:00 pm-5:00 pm

Wednesday:

8:00 AM-1:00 pm

2:00 pm-5:00 pm

Thursday:

8:00 AM-1:00 pm

2:00 pm-5:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

  • "Blue Ridge Eye Care Associates, PLLC is the best at what they do and make you feel right at home."
    John D.