Please complete the following form in its entirety. You may contact the office with any questions. If you are a parent or guardian, please be sure to write in the patient’s information but sign your own name.
Please note that unless revoked by patient or guardian in writing, this authorization release shall remain valid indefinitely.
Agreement & Release
I certify that I, and/or my dependent(s) have insurance coverage with the companies listed above. I assign directly to Wallingford Eye Care Center and my assigned provider within the practice all insurance benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance; I authorize the use of my signature on all insurance submissions.
My assigned provider at Wallingford Eye Care Center may use my health care information and may disclose such information to the above named insurance companies and their agents for the purpose of obtaining payment for services and determining insurance benefits for the benefit payable for related services.
If at any point your account balance becomes past due over 90 days, it will accrue a $1.00 late fee every 30 days thereafter in addition to a non-negotiable $45.00 fee for our services. If this balance continues to be unpaid, your account will be sent to an outside collection agency in an attempt to collect the outstanding debt. Signing below confirms that you have read and understand this notice.
In the course of providing service to you, we create, receive and store health information that identifies you. It is often necessary to use and disclose this information in order to treat you, obtain payment for our services and to conduct health care operations involving our office.
The Notice of Privacy Practices you have been given describes the uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and services provided here, but also disclosures of your health information as may be necessary or appropriate for you to receive follow up care from another health care professional. Similarly, the use and disclosure of your health information for purposes of payment includes (1) our submissions of your health information to a billing agent or vendor for processing claims or obtaining payment; (2) our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment; (3) our submission of your health information to auditors hired by third-party payers and insurers; and (4) other aspects of payments described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can get an updated copy here at the office.
When you sign this consent document, you signify that you agree that we can and will use and disclose your health information to treat you, obtain payment for our services, and to preform healthcare operations. You also signify that you have received a copy of our Notice of Privacy Practices.
You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment or healthcare operations but as described in our Notice of Privacy Practices, we are not obligated to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.
I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. I acknowledge that I have received the Notice of Privacy Practices from Wallingford Eye Care Center.