Century City Optometric Center
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patient  forms

Download  Our  Patient  Forms

Click on the link to download the form, fill it out and bring it with you to your appointment.
Notice of Privacy Practice.pdf
File Size: 99 kb
File Type: pdf
Download File

Adult Information Form.pdf
File Size: 37 kb
File Type: pdf
Download File

Adult Health History.pdf
File Size: 73 kb
File Type: pdf
Download File

Minor Information.pdf
File Size: 36 kb
File Type: pdf
Download File

minor_health_history.pdf
File Size: 75 kb
File Type: pdf
Download File

Good Faith Estimates

​You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services. You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees. Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
​
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises or call 1-800-985-3059.
Contact Us:
Century City Optometric Center
10390 Santa Monica Blvd, Suite 320
Los Angeles, CA 90025

Phone: (310) 277-2020
Fax: (310) 553-9418
e-mail us


Hours:
Mon, Tue, Wed, Thu 9:00 am - 5:00 pm
Fri 9:00 am - 2:00 pm

Closed for Lunch: 1:00- 2:00pm
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Notice of Privacy Practices
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  • Home
  • Our Practice
    • Our Services
    • Our Doctors
    • Location
    • Contact Us
  • Patient Resources
    • Patient Forms
    • Eye Care Articles
  • Eyewear Gallery
  • Vision Therapy
  • Contact Lenses