Form #2: Notice of Privacy Practice (HIPAA)

Name: Harrel Eyecare Memorial
Address: 8004 S Memorial Dr., Tulsa, OK, 74133-3644, US
Telephone: 918-461-2367
Price range: $000 - $300

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

Print this form

Form #2: Notice of Privacy Practice (HIPAA)

Notice of Privacy Practice

Payment Information

Harrel Eyecare Memorial

Harrel Eyecare Downtown

Harrel Eyecare Midtown

Harrel Eyecare South

Notice of Privacy Practice

Payment Information

Harrel Eyecare Memorial

Harrel Eyecare Downtown

Harrel Eyecare Midtown

Harrel Eyecare South

Call Our Two Offices