top of page

Welcome to the office of


Dr. Kosta A. Koutoulas, O.D.

We look forward to working with you in  maintaining your eye health!
Please fill out this form and submit before arriving to your visit
Are you interesting in refractive surgery (ie. Lasik, IntraLasik, WaveFront)?
Are you interested in myopia control for your child or ortho-k for yourself? ( this is to slow down the progression of your child's nearsightedness through ortho-k lenses, soft multifocal lenses or drops )

Insurance information

Please check if your family has history of any following diseases:

Please check if you have a history of any following diseases:

Your past medial history
Your past ocular history
Please check if you have any following problems
Please check if you have any of following vision/eye problems

HIPAA Notice of Privacy Practices

This Notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully. At Clear Vision Eyecare, we have always kept your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice. The law permits us to use or disclose your health information to those involved in your treatment. For example, a review of your file by a specialist doctor whom we may involve in your care.

We may use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company. We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your information into our computer. We may share your medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy. We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your appointment. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone. In an emergency, we may disclose your health information to a family member or another person responsible for your care. We may release some or all of your health information when required by law. If this practice is sold, your information will become the property of the new owner. Except as described above, this practice will not use or disclose your health information without your prior written authorization. You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request. You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses. As we will need to contact you from time to time, we will use whatever address or telephone number you prefer. You have the right to transfer copies of your health information to another practice. We will mail your files for you. You have the right to see and receive a copy of your health information, with a few exceptions. Give us a written request regarding the information you want to see. If you also want a copy of your records, we may charge you a reasonable fee for the copies. You have the right to request an amendment or change to your health information. Give us your request to make changes in writing. If you wish to include a statement to your file, please give it to us in writing. We may or may not make the changes you request, but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but will add new information. You have the right to receive a copy of this notice. If we change any of the details of this notice, we will notify you of the changes in writing. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W. , Room 509F, and Washington , DC 20201 . You will not be retaliated against for filing a complaint. However, before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy officer at (650) 757-8286. This notice goes into effect as of October 1, 2007.

There is a $50 charge if you miss your appointment without 24 hour notice to our office.

Thanks for submitting! See you soon!

bottom of page