Patient Forms

Welcome to Eye Care & Surgical Center and thank you for allowing us to care for you. Please know that we are committed to providing you with the best possible eye and medical care.

On the day of your appointment please bring with you:

  1. The attached HIPPA Form completed and signed.
  2. A Photo ID: As required by law: We closely monitor our patients’ information to ensure privacy and protection of personal information.
  3. Your Insurance Cards: Please know your copay is due on the day of your appointment.


Coming in for Cataracts

Please kindly allow at least 2 hours for your new patient visit. You will not be having surgery at this first appointment. This appointment allows us to complete important pre-surgical eye testing and provide time for you to meet with your surgeon and surgical counselor, should you decide to have surgery. Your eyes will be dilated. This will cause an increased sensitivity to light. We suggest you have a driver take you home.


Contact Lens Evaluation and Fee

If you are having an eye examination and wear contact lenses, our professional staff will be evaluating your current contact lenses to determine their current status. The fee for this service is collected in addition to your co-pay.  Contacts are not covered by your insurance (medical).

MVA Form Completion and Fee

We are happy to fill out and submit your MVA form when you bring it with you. There is a $15 fee for this service.


It is the patient’s/parent’s/ guardian‘s responsibility to:

  • Be familiar with the benefits of your plan, including co-pays, co-insurance and deductibles.
  • Bring all of your current insurance cards to all visits.
  • Provide our office with current information including address, phone numbers and employer.
  • In accordance with your insurance contract, you must be prepared to pay your co-pay at each visit. If you do not make your co-payment at the time of the visit, you will be charged an additional $10.00 billing fee. We accept cash, checks and most major credit cards for services.

We appreciate prompt payment in full for any outstanding balance. If your account is turned over to our collection agency, you agree to pay any fees imposed by the collection agency in order to collect the overdue amount. Any check payments that do not clear the bank will be subject to a $35.00 returned check fee.

For all services rendered to minor/dependent patients, we will look to the adult accompanying the patient and/or the parent or guardian with whom the child resides for payment.  When presenting insurance cards for a dependent enrolled under a subscriber other than you, please be prepared to supply their name, address, phone number, date of birth and social security number. We request that you inform the subscriber that their insurance has been used.

There will be a $25.00 charge if you fail to show for any scheduled appointments or cancel the same the day as your appointment. Legitimate emergencies will be taken into consideration.

If you have any questions, please feel free to call our offices in Laurel at 301-725-3010. We look forward to seeing you at your upcoming appointment and again thank you for choosing Eye Care & Surgical Center.