Privacy Notice, Assignment of Benefits, and Financial Agreement
The HIPPA Privacy Rule gives individuals a fundamental right to be informed of the privacy practices of health plans and health care providers, how medical information may be disclosed, and how you can get access to this information. The complete HIPPA Privacy Rule is available for you to review upon request.
It is the patient/guardian responsibility to know their insurance coverage. Patients should be aware of their benefits, including which providers are contracted with their plan, covered and non-covered benefits, authorization requirements, and cost share information such as deductibles, co-insurance, and co-pays, and when they are eligible for services. If you are not familiar with your plan coverage, we recommend you contact your carrier directly prior to your services.
I consent to have my prescription to be made digitally available on the patient portal upon payment in full of my examination and contact lens services. I acknowledge that I have received my prescription.
The patient/guardian authorizes payment of all private insurance, medical/surgical benefits, including major medical benefits to go to the Mabee Eye Clinic. A photocopy of this assignment is to be considered as valid as an original. The patient/guardian is financially responsible for all charges regardless of insurance. A parent or guardian must sign if patient is under 18 years old.
Person(s) you allow us to discuss your medical record and/or billing information with: (if any)
Current Vision Correction
Medications / Supplements
Family Health History
Select all that apply.