At Rancho Del Rey Optometry, we value your time. In an effort to save you time in our office, you can download and complete our patient form(s) prior to your appointment. Please fill out a separate form for each person having an appointment.

  • You will need AdobeReader┬« to download and complete the forms. Click to download AdobeReader┬«.
  • Download, print, and complete the required form(s).
  • Download, print, and complete a Vision Insurance form, if applicable.
  • Bring the completed form(s) with you to your appointment.
  • Arrive 15-20 minutes early to your appointment to allow for traffic, parking, and form processing. Please do not arrive any later than your appointed time.
  • Expect your time in-office to be approximately 1hour, add an additional 30-40 minutes if eye dilation is requested or required.

Patient Health History Forms

Please complete this form as it lets us know the history and current state of your health.

HIPPA and 60-Day Prescription Service Guarantee Forms – Required
Please sign this form to acknowledge how your health information is protected. At RDR Optometry we do not disclose any of your personal information to anybody except how demanded by Law or for insurance and payment processing.

Please print, read, and sign to acknowledge the Office Policy. Our Service guarantee explains how you and your Doctor help each other to get the most of your vision and time together.

Download them here.

Vision Insurance Forms

Please note that Vision Insurance is typically a separate entity from Medical Insurance. RDROptometry is not a provider for Medical Insurances in any form.

As the direct or affiliate provider for the following Vision insurances, we will verify exam benefits and co-pays, obtain an exam authorization and process the exam claim for you. We currently accept:

Please note that having United HealthCare Medical Insurance does not automatically enroll one in the United HealthCareVision Plan, the Vision Plan is a separate entity from the general medical coverage. Medical treatments of the eye, such as Glaucoma treatment or Cataract Surgery may be covered under the medical plan but are not covered by the Vision plan. The Vision plan covers the basics of the general eye exam and perhaps even corrective materials such as glasses and contacts.

Also, certain UNHVision/Spectera Vision Plans are only covered through an HMO if you have an HMO plan. RDROptometry accepts the non-HMO UNHVision/Spectera Vision Plans.

If you have questions about your insurance coverage please contact the member services phone number on the back of your insurance card.