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Arizona Primary Eye Care
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Arizona Primary Eye Care
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Authorization to Discuss

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Authorization to Verbally Discuss Protected Health Information*Note: This form is optional. In order for this form to be valid, all information must be completely filled out.

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I hereby give permission for Arizona Primary Eye Care and affiliates to verbally discuss the following medical and billing information about me (check all that apply):

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Arizona Primary Eye Care and affiliates has my permission to discuss the above information with:

I understand that I may cancel this permission at any time by notifying Arizona Primary Eye Care in writing, however, canceling permission will not affect any information that has already been released.
I understand that I do not have to sign this form and that I should only sign if I want my medical provider or my clinic to share my information with someone.

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This field is for validation purposes and should be left unchanged.

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Client Testimonials

⭐️⭐️⭐️⭐️⭐️

I’ve been to four different optometrists in the last 20 years. This is by far the best. Prompt, thorough and professional from reception to check out. Very well trained staff.

Kim N.

⭐️⭐️⭐️⭐️⭐️

Dr Nichols and Cindy Valencia are awesome! They truly care and listen to customers needs. The service is amazing and welcoming!

Veronica W.

⭐️⭐️⭐️⭐️⭐️

I have been going to them for many years, always have a great experience. Just picked up my new glasses 🙂

Jennifer M.

⭐️⭐️⭐️⭐️⭐️

The ENTIRE staff at AZ Primary Eye Care are top shelf. My family has been seeing Dr. Nichols for several years now and could not be happier with both the service and products.

Judy F.

⭐️⭐️⭐️⭐️⭐️

The Dr. was great.. clear, concise and kind. The rest of the staff took her lead in those qualities as well.

Heidi L.

⭐️⭐️⭐️⭐️⭐️

Everyone was super helpful and friendly and the staff made sure I understood what was going on with my eyes and my insurance and that all my questions were answered. I would definitely recommend Arizona Primary Eye Care to others!

Brandy E.
Services
  • EYE EXAMS
  • EYE EMERGENCY/INJURY
  • KIDS VISION
  • FRAMES & LENSES
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