Consent Form

INSURANCE CONSENT

I hereby authorize release of information to my insurance companies and payments to be made directly to my providers. This form may be used for all my insurance companies, and I authorize this practice to act as my agent to help me secure payment from my insurance companies. I understand that I am responsible for my bill and am subject to attorney fees, collection fees/charges, and any other charges incurred if my portion of the balance is not paid when due.

MEDICAL RECORDS RELEASE AUTHORIZATION

I authorize Somers Eye Center to release to the appropriate person, corporation, or other entity any diagnostic and therapeutic information (including any treatment for alcohol or drug abuse and any psychiatric or psychological treatment) as may be necessary to determine health care benefits entitlement for me under any insurance policy or other type of health care benefits plans or as may be appropriate for the purpose of analysis or research regarding reimbursement of doctors and other health care providers. I authorize Somers Eye Center to process payment claims for health care services provided to me. I agree to cooperate and execute such other authorizations and releases for the above purposes as deemed necessary by Somers Eye Center upon the practice's request. Somers Eye Center may utilize information in my medical record that is necessary for research for quality improvement purposes.

NOTICE OF PRIVACY PRACTICES

As required by the Privacy Regulations set forth in the Hearth Insurance Portability & Accountability Act of 1996 (HIPAA), Somers Eye Center has made available its Notice of Privacy Practice to me, which describes how a patient's health information is used and shared. I acknowledge Somers Eye Center has offered to provide me with access to its Notice in paper copy. I understand that Somers Eye Center has the right to change this Notice at any time, and if the Notice changes, a current copy may be obtained by contacting Somers Eye Center.

USE OF CONTACT INFORMATION: TELEPHONE CONSUMER PROTECTION ACT (TCPA)

By initialing and signing below, I acknowledge I have reviewed Somers Eye Center's Notice of Privacy Practices where it discusses how the practice may use my contact information. I agree that the practice, along with its affiliates and vendors, may call, text, or e-mail me as set forth in the Notice, including, but not limited to, using an automated telephone dialing system and/ or an artificial voice. I further understand that I can opt out at any time by notifying the practice and/or the affiliate/vendor.

FINANCIAL POLICY AND PAYMENT GUARANTEE

I have read and fully understand the Patient Financial Policy set forth by Somers Eye Center, a copy of which has been provided to me, and I agree to the terms of this financial policy. I agree that the terms of the financial policy may be amended by the practice at any time without prior notification to me, the patient.

MEDICARE BENEFITS CONSENT

If I am covered by Medicare, I certify that the information given in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my, as the patient's, behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment to the patient.