Payment and Fees:
Payment is expected at time of service for fees not allowable by your insurance carrier. Insurance companies do not guarantee payment. Any additional balance will be billed to your account. We do not file secondary insurance.
Assignment of Benefits:
I hereby assign all medical and/or vision benefits, to which I am entitled, from my insurance plan to Miller Vision Specialties.
Authorization to Release Information:
I authorize Miller Vision Specialties to release all information pertaining to patient treatment to his/her insurance companies and to any other physician or health care provider to whom the undersigned may be referred.
Consent to Treat:
I authorize medical treatment of myself/minor by the physicians of Miller Vision Specialties.
Notice of Privacy Practices:
I understand that under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can be used to:
*Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
*Obtain payment from third party payers.
*Conduct normal healthcare operations such as quality assessments and physician certifications.
A copy of the Notice of Privacy Practices containing a more complete description is available within the office. I understand this office has the right to change the Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy.