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Patient Forms

Printable Patient Forms

Read more about your HIPAA Rights – Download & Print

Patient Registration – Download & Print

Records Release Authorization – Download & Print

Notice of Patient Nondiscrimination – Download & Print

Online Patient Form

Patient Registration Form – Submit Online


For our office to operate effectively and provide the best service to you and your family we need your cooperation with the following policies. Your clear understanding of these policies is very important. Please be aware that violation of these policies may result in dismissal from our practice. Please let us know if you have any questions or concerns.

Our office is open Monday 10:00 am to 7:00 pm, Tuesday-Friday 8:00 am to 5:00 pm. Our office is closed in observance of major holidays.

First time patients are asked to arrive 15-20 minutes EARLY to allow adequate time for completing the initial paperwork, or you may download the forms from and bring them to your appointment.

We strive to provide the best eye care for our patients. While we make every effort to provide prompt on-time service, the eye care needs of each individual may vary due to eye health conditions. We therefore appreciate your understanding and patience. If you have any suggestion or complaint for our office, please let us know. We ask that you please complete the survey sent to your email after your annual eye examination. We request that only appropriate language be used in front of our office staff and other patient at all times.

For safety reasons, we depend on parents to properly supervise their child(ren) at all times. Under no circumstances should a child under the age of 10 be left unattended. We also require a consent form signed by a parent or legal guardian to legally provide eye care to minors under the age of 18. Minors 15 years of age and younger must be accompanied by a parent or legal guardian.

Please notify our office in writing of any changes of address, telephone, billing or contact information. It is imperative that we have the most current information on file.

If you are more than 15 minutes late when arriving to a scheduled appointment, you may be asked to reschedule.

We understand personal matters do occur that may necessitate a cancellation; therefore we kindly ask for at least a 24-hour advance notification.

1st No Show- Our office will call you to remind you of your missed appointment.

2nd No Show- Our office will notify you by mailing you a letter and a policy reminder.

3rd No Show- Our office will notify you by mailing a final certified letter indicating termination of services. Termination of services will include a grace period of 30 days for prescription refills. It will be your responsibility to find a new provider.

Each patient is asked to bring a list of all medications currently being taken. This is to assure that everyone understands the name of the medication you are taking. Many medication names sound alike and are spelled similarly.

All prescription refills require 24-48 hour notice to our office.

Medical records may be released to a new physician with a signed consent by the patient or the patient’s legal guardian.

Records will be released to the new physician at no charge to the patient.

Medical records released to the patient are subject to copying fees.

Records will be mailed only after receipt of proper release, improperly filled out forms may delay your request.

Payment is expected at time of service, including co-payments. You will be asked to show your insurance cards at every appointment to help ensure account accuracy.

Glasses and contacts are to be paid in full at time of order.

Our office will submit claims for insurance carriers with which we participate. We cannot guarantee that all services we provide or recommend are covered by your insurance. Any quote given is not a guarantee of payment as this is an estimate only, actual claims are determined at the time the claim is processed by your insurance company.

However you are responsible for verifying and knowing your insurance coverage, deductible, co-payment, etc. as the insurance policy is between you and your insurance company.

Patients with past due balances, not insurance related, must make payment arrangements prior to future appointments being made.

If you have an urgent medical vision situation when the office is closed, call our office at (712) 527-4468 you will be directed by our voicemail how to contact us.

If you are experiencing a medical emergency or you believe you are experiencing a life threatening situation, call 911 immediately.

YoungVisionCare COVID WebtileBanner Updated

Due to the continuing escalation of concern about the Coronovirus, we are now only seeing patients with an urgent need during the month of April.

Our office will be closed to regular business beginning Tuesday, April 7, 2020. We will notify you when our office is seeing patients on a normal basis.

• If you are experiencing any significant changes in your vision or eye comfort, please call 712.527.4468 or 1.800.766.8705

• If you are in need of eye supplements, please leave a message at 712.527.4468. We will contact you to make arrangements.

• Contact your pharmacy if you need drops/medications refilled.

• If you have additional inquiries, leave a message at 712.527.4468

*Messages will be checked on a regular basis*

We are also postponing our April 30th celebration event for our 70th year of business.

Thank you for your patience and understanding during this time.Please be safe!

-Dr. Jacque Young and Staff at Young Vision Care