NOTICE OF PRIVACY PRACTICES: I have been shown or offered a copy of Precision Eye Care’s statement on privacy policies that is displayed at the front desk.
AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Precision Eye Care, LLC to release any medical or incidental information that may be necessary for medical benefit in processing applications for financial benefit. This includes, but is not limited to, my insurance company, rehabilitation services, social security administration, and worker’s compensation.
CONSENT FOR TREATMENT: I hereby authorize Precision Eye Care, LLC to administer diagnostic and medical procedures as may be necessary for proper health care.
OFFICE POLICY ON PAYMENT: I understand that I am responsible for payment of all charges. As a courtesy, my insurance will be billed for me. It is my responsibility to pay any deductible, co-pay or any other balance not paid by my insurance company. I authorize insurance benefits to be paid directly to the provider. I understand that any remaining balance on my account after 30 days will accrue interest at an annual rate of 18% and that I will be responsible for any reasonable costs associated with the collection of past-due balances.
VISION PLAN COVERAGE: I understand that only one vision plan may be used for exam/materials per visit, per patient and that the vision plan to be used must be chosen before the exam occurs and cannot change at a later date.