Patient Forms

Blaine Eye Clinic is pleased to offer our patients the convenience of completing new patient forms online! Click the link below to complete our secure online registration and health history form.

New Patient Registration

Other Forms:

 Transfer of Medical Records InfantSEE Patient History Form Contact Lens Policy

When you come to your visit, you will be required to sign the following forms. In order to save you time in our office, please review these forms below ahead of time. We will provide printed copies for your review at your visit.

–Notice of Privacy Practices

–Financial Agreement

The effective date of notice: 11/27/2013


Blaine Eye Clinic Optometrists P.A.
12170 Aberdeen St NE, Blaine MN 55449
Fax: 763-757-3328
Contact: Brenda Anderson


We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.


The most common reason why we use or disclose your health information is for treatments, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; testing or examining your eyes; prescribing glasses, contact lenses, or eye medications and faxing them to be filled; showing you low vision aids; referring you to another doctor or clinic for eye care or low vision aids or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or vision care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are financial or billing audits, internal quality assurance, personnel decisions, participation in managed care plans, defense of legal matters, business planning, and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.


In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

  • when a state or federal law mandates that certain health information be reported for a specific purpose;
  • for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the U.S. Food and Drug Administration regarding drugs or medical devices;
  • disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence;
    uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
  • disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
  • disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office, or to report a crime that happened somewhere else;
  • disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ tissue donations;
  • uses or disclosures for health related research;
  • uses and disclosures to prevent a serious threat to health or safety;
  • uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
  • disclosures of de-identified information;
  • disclosures relating to worker’s compensation programs;
  • disclosures of a “limited data set” for research, public health, or health care operations;
  • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
  • disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information;

Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your eye care.


We may call, email, text or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call, email, text or write to notify you of other treatments or services available at our office that might help you.


We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation, you will give us a properly completed authorization form, or you can use one of ours.

If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.


The law gives you many rights regarding your health information. You can:

  • ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
  • ask us to communicate with you in a confidential way, such as by phoning you at work rather than home, by mailing health information to a different address, or by using email to your personal email address. We will accommodate these requests if they are reasonable and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
  • ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or 60 days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
  • ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for an amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or email shown at the beginning of this Notice.
  • get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law, we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or email shown at the beginning of this Notice.
    get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax, or email shown at the beginning of this Notice.


By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new one in our office and have copies available in our office.


If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax, or email shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.


If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this notice.


At your upcoming new patient visit to Blaine Eye Clinic, you will be required to sign the financial agreement. As a convenience to our patients, we have provided this information below so you can become familiar with it ahead of time:

Blaine Eye Clinic Financial Agreement

MEDICARE: I request that payment of authorized Medicare benefits be made on my behalf to Blaine Eye Clinic for services furnished to me by Blaine Eye Clinic. I authorize any holder of medical information about me to release to the Centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment is made and authorizes the release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Blaine Eye Clinic accepts the charge determination of the Medicare carrier as the full charge, and I am responsible only for the deductible, coinsurance and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier.

RELEASE OF INFORMATION: Blaine Eye Clinic may disclose all or any part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, psychiatric illness, communicable disease, or HIV, to any insurance or health care provider (1) which is or may be liable or under contract to Blaine Eye Clinic for reimbursement for services rendered, and (2) for necessary referral to specialist and/or family physician for continued patient care.

INSURANCE COVERAGE: Blaine Eye Clinic contracts with most of the major health plan payers; however, I acknowledge that it is my responsibility to confirm specific health plan coverage and benefit levels. Our business office is available for assistance at 763-757-7000. I understand that I am responsible to pay for any health care services for which my health plan denies coverage. If copayments and/or deductibles are designed by my insurance company or health plan, I agree to pay them to Blaine Eye Clinic. However, it is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill.

FINANCIAL AGREEMENT/NON-COVERED SERVICES: The undersigned accepts full, primary financial responsibility for all items or services, which are ultimately determined by the health care service plans not to be covered. Examples of non-covered services may include but are not limited to, treatment or tests not authorized by the health care service plan. The undersigned agrees to cooperate with Blaine Eye Clinic to obtain necessary health care service plan authorizations. I agree that in return for the services provided to the patient by Blaine Eye Clinic, I will pay my account at the time service is rendered or will make financial agreements satisfactory to Blaine Eye Clinic for payment. If an account is sent to an attorney for collection, I agree to pay collection expenses and reasonable attorney’s fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance insuring the patient, or any other party liable to the patient, are hereby assigned to Blaine Eye Clinic. If copayments and/or deductibles are designed by my insurance company or health plan, I agree to pay them to Blaine Eye Clinic.

EYE DROP ADMINISTRATION: I understand, as a patient, or parent/guardian of a minor child, that my eyes may be dilated as part of the exam. Dilation and other drops used during my visit can affect vision and function for a period of time. By signing below, permission is granted to dilate and give other drops.

(OPTIONAL): You have my permission to release any information including the diagnosis and records of any treatment or examinations rendered to me or my child to the following person(s):

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Phone: (763) 757-7000
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