Forms

Welcome to Pediatric Ophthalmology Associates!  If you’ll be seeing us soon for an appointment and this is your first time to our office, please download, print, and complete the Registration and HIPAA (Health Insurance Portability and Accountability Act) forms for your visit.  Even if you’re not new but your information has changed (i.e. address, insurance, etc.) please update this information for your file by filling out a new Registration form.  Completion of these forms prior to your appointment is not necessary, but will most likely reduce your wait time when you arrive.

You will need Adobe Acrobat to be able to access these forms.  If you don’t have Acrobat installed on your computer, click here to install it for free.

Registration (PDF)

HIPAA (PDF)

HIPAA Español (PDF)

Refraction Policy (PDF)

Financial Policy (PDF)

 

If you need to have medical records released from our office to a parent, guardian, or doctor, please fill out the following form and either mail it to our office at:
515 N. 98th St.
Omaha, NE 68114,
or fax it to us at (402) 399-8170

Records Release Authorization_from Pediatric Ophthalmology Associates (PDF)

 

If you need to have medical records released to our office from your current physician, please fill out ONE of the following forms depending on your doctor:

Records Release Authorization_to Dr. Sebastian Troia (PDF)

Records Release Authorization_to Dr. Robert Troia (PDF)