Patient Center



The patient center offers forms, policies, guidelines and patient education for Affleck M.D. Eye Care. Some PDFs can be printed for later reference while other should be filled-out and brought to the office before appointments.

New Patient Paper Work

Please bring completed forms to the office before your appointment. You will need to download the paper work, fill it out and print it. Or you can print the paperwork, handwrite the data. Thank you in advance for you effort on this matter.

Records Release

If you would like us to receive your records from your prior eye care provide, just fill out this form. Either bring it to the office and we will fax it for you, or mail it to your former provider.

Notices of Privacy Practices (NPP)

According to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The HIPAA Privacy Rule requires health plans and covered health care providers to develop and distribute a notice that provides a clear, user friendly explanation of individuals rights with respect to their personal health information and the privacy practices of health plans and health care providers. This page provides options for meeting the requirement to create notices of privacy practices (NPP). Click here for more information.


We may be able to help find funds for under insured patients. Mountain view charity (MVC) provides health-care grants that help southeastern Idaho patients receive medical treatment. It is designed to help patients maintain their insurance coverage or to fill in the gaps that insurance neglects.

Medical Financial Assistance can include future expenses of:  Office Visit Co-Pays, Deductibles, Diagnostic Testing,

Lab Work, Doctor Appointments and Hospital Costs.  All payments are sent to the provider, clinic or hospital directly.

Funds requested can only be applied to patient’s out-of-pocket costs.  Uninsured patients are required to seek health insurance coverage. If coverage is obtained, applicant needs to provide proof of insurance. If patient is denied insurance, applicant needs to provide a letter of insurance coverage denial. Funding will not occur until this step is met.  FUNDING IS ONLY APPROVED FOR FUTURE COSTS. PLEASE FILL OUT THIS FORM AND RETURN IT 30 DAYS BEFORE PLANNED SERVICES to Affleck M.D. Eye Care at 2900 Valencia Drive, Idaho Falls, Id 83404.