Form #2: Notice of Privacy Practice (HIPAA)

Post author By harreleyecare
Post date April 12, 2023

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

MM slash DD slash YYYY
Signature of Patient or Guardian
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.
Signature of Patient or Guardian:
Date

MM slash DD slash YYYY
We are glad to answer any questions regarding your insurance benefits. Thanks!

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