Form #2: 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). Patient Name First Last Date Date Format: MM slash DD slash YYYY Signature of Patient or GuardianPayment Information Payment Information – Please read and sign below. Thank you I authorize you to bill my insurance for any applicable services or products. I understand that payments for noninsured services are due the same day services are rendered . 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. Signature of Patient or Guardian:Date Date Format: MM slash DD slash YYYY We are glad to answer any questions regarding your insurance benefits. Thanks! Print this form
