Patient Forms

Downloadable patient forms that you can print and fill out before your next visit to Basin Vision Center in Cody

For your convenience, we have created the following pages to provide you with a list of the insurance carriers we accept at our Cody optometric office, as well as several downloadable forms to save you time at your next appointment.

Downloadable Forms

• Notice of Privacy Practices [PDF] – Required for any new patient or existing patient who recently turned 18 years of age.
• Acknowledgment of Notice of Privacy Practices [PDF] – Required for any new patient or existing patient who recently turned 18 years of age.
• Patient Intake Form [PDF] – Required for any new patient.
• Medical History Form [PDF] – Required for any new patient or an existing patient with several changes in vision or medical history.
• Medicare Benefit [PDF] – This form authorizes Basin Vision to submit to Medicare on your behalf. It also states that if you have not met your annual deductible with Medicare, any charges from Basin Vision Center might be applied to the deductible, which would then become your responsibility. Only a signature and date are needed for this form.
• Medicare Permission to File Secondary Insurance Form [PDF] – This form gives permission to Medicare to send your claim directly to your secondary insurance (if applicable). Only a signature and date are needed.
• Medicare Refraction Charge Form [PDF] – This form lets you know in advance that Medicare does not cover the refraction cost, which is what the doctors do to check your prescription. It is a $50 cost and will be the patient’s responsibility at the time of the appointment. Please select one of the options on the form, sign, and date.