Skip to main content
Call 860-238-3620
Book Westfarms Mall Appt
Call 860-238-3920
Book Newington Appt

Inside Lenscrafters

Inside Lenscrafters

Home » Contact Us » HIPAA/Ins/Authorization

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.

  • MM slash DD slash YYYY
  • AUTHORIZATIONS

  • 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.

  • MM slash DD slash YYYY