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Patient HIPPA Form

  • Notice of Privacy Practices & Office Policies

    • Your Insurance policy is a contract between between you and your insurance company. You are ultimately responsible for payment regardless of your insurance's arbitrary determination of usual and customary fees.
    • Knowledge of benefits and eligibility is your responsibility. All insurance plans are unique and individual. Our staff may not have all information specific to your plan available to them before your visit.
    • Insurance claims are not backdated. All services and orders are billed on the date of service.
    • All services and orders are billed on the date of service.
    • All returned checks are subject to a $35 insufficient fund fee.
    • Full payment must be made in advance for your eyewear. Eyeglass orders not paid in full can be placed on hold for up to 30 days. You are responsible for any non-covered items and any difference in fees above and beyond your insurance company's allowable amount.
    • All eyeglass orders are custom made. Cancellations will not be accepted once the order is placed. Cancellations will not be accepted once the order is placed.
    • Warranty information:Eyeglass frames and/or lenses have a one year, one time warranty. This is for scratches and/ or normal wear and tear to be determined by the discretion of the optician. $20 exchange fee will apply for all warranty products.
    • An Adult is required to accompany all children under the age of 18. The adult accompanying the minor is responsible for payment of services regardless of relationship or financial arrangement.
    • If you No Show for an appointment, we have the right to charge a $50.00 Fee.If you no show more than 3 times, you may no longer be seen in this office.
    • Mandatory Retinal imagery will be taken at each annual exam at a charge of $15.00.
    • We have the right to dismiss a patient at anytime from the practice.Without notice we reserve the right to terminate our relationship with you at anytime without notice or reason.
    • Notice of Privacy practices. We respect our legal obligation to keep your health information private. We are obligated by law to give you notice of our privacy practices listed on this form.
    • List any persons/Organizations you are authorizing to have access to your records or to whom we may speak with on your behalf.
    By Signing below I Authorize:
      – This form is to serve as a lifetime signature on file for my account.
      – I have read/understand the notice of privacy practices and I further consent to the release of my health information for purposes of treatment,payment, and health care operations and as authorized or required by law in the circumstances described in the notice of privacy practices.
  • (Parent or Guardian)
  • Date Format: MM slash DD slash YYYY