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15 & Under Form: Notice of Privacy Practice (HIPAA)

  • Please Sign Both the Privacy Practices & the Payment Information

    Notice of Privacy Practice

    I acknowledge that I have read or have had the opportunity to read the Notice of Privacy Practices (available at the front desk).
  • MM slash DD slash YYYY
  • Payment Information

    Payment Information – Please read and sign below. Thank you
    1. I authorize you to bill my insurance for any applicable services or products.
    2. I understand that payments for non­insured services are due the same day services are rendered .
    3. I understand if I have not met my health insurance deductible and I’m receiving medical eyecare that 50% of the bill is due today, and any balance remaining after being processed through insurance will be billed to me.
  • MM slash DD slash YYYY
  • We are glad to answer any questions regarding your insurance benefits. Thanks!

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