HIPAA Payment Form

Notice of Privacy Practice

Please sign for the private practice and payment information.

I acknowledge that I have read or have had the opportunity to read the Notice of Privacy Practices.

1. I authorize you to bill my insurance for any applicable services or products.
2. I understand that payments for non-insured services are due the same day services are rendered.
3. I understand that if I have not met my health insurance deductible and I’m receiving medical eyecare, 50% of the bill is due today, and any balance remaining after being processed through insurance will be billed to me.
4. I understand that I am financially responsible for all charges whether or not paid by insurance.

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