Low Vision Patient Form

Authorization To Disclose Health Information

NOTICE: Federal Law states that if a patient is over 18 years of age, The Optometry Center for Vision Therapy (OCVT) cannot share your healthcare information without your express written consent with any person(s) including a parent or guardian. Your signature on this form indicates you are giving permission to OCVT to share healthcare information with the person(s) indicated below. This authorization is voluntary and can be revoked at any time by completing and mailing a revocation to either of OCVT's locations (form may be requested from either office). Please inform a Patient Services Coordinator if you wish to keep a copy of this authorization for your records.
I hereby grant permission to OCVT to share patient's healthcare information with the following person(s):

Authorization and Acknowledgements

These authorizations/acknowledgements cover services rendered to the above patient for today and all future dates of service. Please initial at the end of each statement to show that you have read and agreed to all authorizations.

• I hereby acknowledge that I have been offered a copy of The Optometry Center for Vision Therapy's Notice of Privacy Practices (A copy is available upon request).
  
• I give consent for the patient above to be treated by The Optometry Center for Vision Therapy (OCVT).
  
• I authorize OCVT to use and/or disclose the health information for the patient above as needed for the following purposes: for optimal treatment, to facilitate payment, and to provide applicable heath care procedures.
• I authorize OCVT to exchange pertinent information (including copies) found within the patient's evaluation records with other professionals who may be involved in providing care for the patient and my insurance carrier. I also consent to the vision care provided by the doctors and staff of OCVT, which may or may not include diagnostic and treatment procedures.
• Payments must be made at the time services are rendered. I understand that if my account remains unpaid, it may be sent to collections and collection costs of up to 25% will be added to the account balance and become my responsibility.
  
• The Optometry Center for Vision Therapy is a private pay practice, and therefore does not accept insurance of any kind. It is the responsibility of the patient or patient's parent(s)/guardian(s) to contact and have discussions with their insurance company and ultimately file their claim. Your insurance company may deny or place limits on any claims.

By signing below, I consent to the above listed providers receiving updates and reports from OCVT for collaboration on my care, including calls, record sharing, and school observations as applicable.

My signature below authorizes this clinic to share any of the patient’s medical records via phone or electronically, and to schedule school observations as the provider deems necessary. I understand that I may revoke this authorization at any time except for actions already taken based upon it. I understand that to revoke this authorization, I must submit a written revocation to the Patient Services Team via fax, mail, or in-person. I understand that this release does not expire unless or until a written revocation is received. I understand I may request a copy of this document at any time.

FOR RETURNING PATIENTS ONLY: Please update the patient paperwork by initialing/dating by each change and Sign/Date below:

I hereby authorize The Optometry Center for Vision Therapy to share medical information of the patient named above.

I understand that:

• I may revoke this authorization in writing at any time, except for any actions already taken based upon it.
  To revoke this request, please submit the revocation in writing to either OCVT address listed above via fax, mail, or in person.
• I understand this authorization will not expire until a written revocation is received from the above-listed patient.
• I may request a copy of this form after it is signed.

The Optometry Center for Vision Therapy is a private pay practice. This means we do not accept insurance of any kind, and you are responsible for payment in full at the time the service is rendered. You are responsible for filing a claim with your insurance company for services rendered, if you choose to do so. Treatments may be covered under major medical insurance, but we cannot guarantee coverage. The amount of coverage you receive, IF ANY, will depend on your specific insurance policy. We encourage you to seek coverage reimbursement from your insurance company. Under all forms of major medical insurance, you have the right to request a review of any service that is denied coverage or for which coverage is limited. If you believe that your plan has incorrectly evaluated the claim for coverage, acted arbitrarily, or discriminated unfairly against you, we encourage you to request a review.