HIPAA/Ins/Authorization

I hereby acknowledge that I received a copy of this office's Notice of Privacy Practices. I further acknowledge that a copy of the current notice will be posted in the reception area, and that I may request a copy of any amended Notice of Privacy Practices at each appointment.

It is customary to pay for all services on the date rendered unless other arrangements were made. The patient and the guarantor are responsible for all deductibles and co-pays at the time of the visit and any other fees in accordance with insurance contracts. The patient and guarantor are responsible for all elective or non-covered services and any services that are not considered medically necessary.

I authorize the release of any medical information necessary to process this claim and I request that payment of medical benefits be made directly to Westfarm Eye Associates. I hereby acknowledge that I am fully responsible for payment as listed above.