In order to assist us in processing your insurance claim, allow for communication with your other health care providers, and HIPAA regulations please read and sign the following:

I authorize Clarity Vision Care to bill my insurance carrier on my behalf. I request that payment of authorized benefits be made to this clinic for any services furnished to me by Clarity Vision Care. We do not guarantee the accuracy of benefit information given to us by insurance companies. I understand I that I am financially responsible for any balance not covered by my insurance carrier or that my insurance carrier does not pay. I understand once the insurance I use at time of check out has been billed no changes can be made such as withdrawing one insurance to bill another. I authorize any holder of medical information about me to release to my medical insurance carrier any information needed to determine the benefits payable for related services for myself and/or my dependents.

Authorization to release medical information:

I authorize the release of medical information regarding myself /my dependents and my current condition to my referring physicians.

Notice of Privacy Practices – Acknowledgement:

We keep a record of the health care services we provide to you. You may request a copy of your medical record in writing. We will not disclose your record to others unless you direct us to do so or unless legal authorities authorize or compel us to do so. You may request a copy of your record or get more information by contacting Clarity Vision Care. Our notice of privacy practices is available at the reception desk. We will be happy to provide you with a copy per your request. I acknowledge the notice of privacy practices has been offered to me and is readily available in accordance with the Health Insurance Portability and Accountability Act.