Patient Info & Forms

Stay ahead of schedule with online forms

Your life is busy. Simplify your day by filling out the forms you need to complete before your first visit. If you have any question, contact us today!

It's easy - just print and fill out the forms, bring them with you to your appointment, and present them to our friendly front desk staff. Your appointment will go even faster and more smoothly! PDF links have been provided below as well as an online form to fill this information out digitally.

Brinegar Eye Care accepts and files many medical and vision plans including Aetna, Anthem, Anthem Blue Vision, Blue View Vision, Caresource, Cigna Vision, Cook, Eyemed, First Health Network, Humana Vision, Medicare, SIHO, Sagamore, Tricare, VCP, and VSP. Contact us with any additional insurance questions and/or visit our frequently asked questions page.

  • You will need AdobeReader® to download and complete the forms.
  • Download the required form(s). Print out the form(s) and complete the required information.
  • Fax your printed and completed form(s) to our office or bring them with you to your appointment.


  • Click the link below
  • Fill out form(s) online
  • Click Submit and we will respond as soon as possible!

Call us today at (812) 339-7995 to schedule an appointment.

Fill out the forms below before your first appointment:

Note: Read carefully and complete forms in black ink.

Patient Form 1 - Fill Online Form Here

Patient Form 2 - Fill Online Form Here

Also, please review our Privacy Practices:

Privacy Practices

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For an appointment with our expert and caring staff, call Brinegar Eye Care today.

(866) 575-7649

[email protected]

Brinegar Eye Care, LLC


4001 E 3rd St Ste 8,
Bloomington, IN 47401


9:00 am - 5:00 pm


9:00 am - 5:00 pm


9:00 am - 5:00 pm


9:00 am - 5:00 pm


9:00 am - 5:00 pm






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