Request to Update or Cancel Eyefinity Solutions/Services

The online form supports the following types of account changes:

Cancellation/Return – ends access to and billing for a product, provider, or location.
Ownership Change – transfers all Eyefinity paid products exactly as they are across ownerships.
- Any services your practice does not want transferred should be cancelled first.
- This process does not update credentialling with VSP^® Vision Care nor any affiliated company.
Address/Phone/Email/TIN Update – changes the practice account information with Eyefinity.
- Additional system configuration may still be required. Be sure to contact your support team for instructions to update Eyefinity solution system configuration.
- For VSP providers you must first update your records with VSP before updating your Eyefinity account; please email ProviderNetworkDevelopment@VSP.com.

System changes may take 10 business days to process, we cannot guarantee processing on a specific date. Changes cannot be made retroactively. If you have changes with different effective dates please submit a separate form for each change.

Effective Date of Change

Practice Name

Your Eyefinity account number can be found by logging into Eyefinity.com and clicking "Change Password".

Practice Eyefinity Account Number

Practice Phone Number

Submitter’s First Name

Submitter’s Last Name

Please include the best email address to contact your office about this change request should we have questions. Please note: If this email isn’t on file for the practice, we may reach out to the primary user for authorization of this change request.

Point of Contact Email

Please select the appropriate request below. Any request will be subject to the terms and conditions of your contract. *If you would like to add services please contact your Account Executive at 800-269-3666, option 2.

Request Type

Is there an ownership change?

Yes No

What would you like to cancel?

Are you fully cancelling Eyefinity Digital Marketing Services?

Yes No

Would you like to cancel a Website Bundle or an Optimizer Service?

Website Bundle Optimizer Service

Which Website Bundle would you like to cancel?

Eyefinity Digital Marketing Base Eyefinity Digital Marketing Advanced Eyefinity Digital Marketing Pro Eyefinity Digital Marketing Deluxe Eyefinity Digital Marketing Ultimate Other

Which Optimizer service would you like to cancel?

Eyefinity Digital Marketing Services – Optometrist Network Eyefinity Digital Marketing Services – Automated Review Reputation Management Eyefinity Digital Marketing Services – Directory Listing & Google Eyefinity Digital Marketing Services – Get Set Pro w/ Scheduler Eyefinity Digital Marketing Services – Scheduler (non Eyefinity PM) Other

Will you be cancelling the product or service completely?

Yes: All services, providers, and locations will be cancelled. No: You’ll have the ability to cancel specific services, providers, or locations.

Please select items to cancel:

Add-On Services Only Authorized Practitioner(s) (Providers) Authorized Site(s) (Locations) Eyefinity EHR ExamWRITER eWebExtra Eyefinity PatientNavigator

All integrated Add-On Services, Authorized Practitioner(s)/Providers, and/or Authorized Site(s)/Locations will be cancelled when cancelling your PM and/or EHR Solution.

Example: If you have Equipment Interface, ePrescribe, and Secure Messaging integrated with OfficeMate^® and ExamWRITER^®, by cancelling OfficeMate^® and ExamWRITER^® all integrated products will also be cancelled.

For cloud products customer may obtain a copy of the Medical Records stored in the Services by providing Eyefinity with a written request for such records within fifteen (15) days of the effective date of such termination. After the thirty (30) day period commencing on the effective date of termination or expiration of an Order, Eyefinity shall have no obligation to maintain any copies of or provide any copies of the Medical Records (including any Applicable Patient Records). For full details please refer to section 8.5 of the Cloud Agreement.

Please select PM/EHR Solution you wish to cancel

AcuityLogic Eyefinity Practice Management Eyefinity EHR OfficeMate ExamWRITER Other

For Eyefinity Practice Management copies of patient records will be provided in CSV format and only include Patient Demographics and Appointments.

Would you like an extract of your Eyefinity Practice Management data?

Yes No

For Eyefinity EHR Eyefinity will initiate the extraction of all Finalized EHR visits in PDF format within 15 days of processing your request to return Eyefinity EHR. Eyefinity will extract only those EHR Visits that have been finalized. This means visits in preliminary or charge sent status will not be extracted. In order to receive all visits you have 15 days to ensure all visits are finalized.

Would you like an extract of your Eyefinity EHR data?

Yes No

* The extraction process may take between 10 to 30 days. Any visit in a preliminary or charges sent status once the extraction process begins will not be delivered to you. Once the data is available, we will deliver it within 3 business days.

For Data Extraction Service limitations please refer to section 2.1.2 of the Cloud Agreement.

Please select add-on services you wish to cancel:

Equipment Interface DHIT (Secure Messaging) EPN (Electronic Patient Notifications) ePrescribe for ExamWRITER Eyefinity PatientNavigator Image Management IRIS Registry Other

If you are cancelling your last full-time provider, your entire EEHR account will be cancelled. If you are cancelling your last ExamWRITER eRx provider, your eRx will be cancelled.

Please select products you wish to cancel for Authorized Practitioners/Providers

AcuityLogic Eyefinity Practice Management Eyefinity EHR ePrescribe for ExamWRITER Image Management for Eyefinity EHR Registry Trizetto Secure Messaging for ExamWRITER Other

If this is your last provider (or only provider), please change your selections in the menus above. For “What would you like to cancel?” please change your selection to PM/EHR solution so that we can cancel the product.

If this is your last location (or only location), please change your selections in the menus above. For “What would you like to cancel?” please change your selection to PM/EHR solution so that we can cancel the product.

Cancelling your EPM and EHR also cancels your eWebExtra. Please answer the following questions regarding your eWebExtra Website.

Effective date to cancel eWebExtra

In addition to your website being canceled, the following associated eWebExtra services will also be terminated.

Website URL address
Website associated e-mail addresses
Auto-population of website link on VSP "Find My Doctor"^*
Integrated Online Forms
Integrated Online Appointment Scheduling
Eyewear Promotions, marketing services

*Your VSP "Find My Doctor" profile will NOT be removed only the link to your website will be removed.

Do you wish to keep your website domain?

I DO NOT wish to keep domain (your domain will expire and be available for others to purchase) I wish to keep and transfer domain to my GoDaddy

System changes may take 10 business days to process, we cannot guarantee processing on a specific date. Changes cannot be made retroactively. If you have changes with different effective dates please submit a separate form for each change.

Effective Date of Ownership Change

Is the Business TIN changing?

Yes No

New point of contact full name

New point of contact email

New point of contact phone number

Will the new buyer require training?

Yes No

Is Your Account VSP Credentialed?

Yes No In process

Your Eyefinity details sync to your VSP credentialing. Please report all practice address, tax ID, or phone number changes to your VSP credentialing representative or email ProviderNetworkDevelopment@VSP.com

Name of Practice

Business TIN

Practice Address: Billing

Practice City: Billing

Practice State: Billing

Practice Zip: Billing

Physical Practice Address (same as billing)

Yes No

Practice Phone Number

Please include the best email address to contact your office about this change request should we have questions. Please note: If this email isn’t on file for the practice, we may reach out to the primary user for authorization of this change request.

Point of Contact Email

Please complete the following fields even if information remains the same

NEW Name of Practice

NEW Business TIN

NEW Practice Address: Billing

NEW Practice City: Billing

NEW Practice State: Billing

NEW Practice Zip: Billing

NEW Physical Practice Address (same as billing)

Yes No

NEW Practice Phone Number

Please include the best email address to contact your office about this change request should we have questions. Please note: If this email isn’t on file for the practice, we may reach out to the primary user for authorization of this change request.

NEW Point of Contact Email

Are you currently using OfficeMate?

Yes No

Electronic Signature Agreement

By entering your full name below, you are agreeing that (a) your electronic signature will be enforceable as and to the full extent of a hand-written signature as an original for enforcement/enforceability of this documented request, whether in court (state or federal), arbitration or otherwise, (b) you will not raise any defenses or invoke regulatory or statutory claims attempting to invalidate the enforceability of this documented request, (c) you are authorized by the contracting party to submit this request, and (d) all information provided with this request is true and accurate.

Please provide any additional information that may assist in processing your request.

eSignature (First and Last Name)

By selecting "Agree", you acknowledge you have read, understand, and accept the Terms and Conditions of Use, including Eyefinity's Privacy and Security Policy and Notice of Privacy Practices.

Agree Do not agree

First Name

Last Name

Email Address

Practice Phone Number

Select Topic

Website Services Support Eyefinity EHR Support Eyefinity Practice Management Support OfficeMate Support AcuityLogic Support Request Training Other

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