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Insurance Authorization

• I authorize and request my insurance company to pay directly to the eye doctor or ophthalmic group insurance benefits otherwise payable to me.

• I understand that my insurance carrier may pay less than the actual bill for services and I agree to be responsible for payment of all services rendered to me or my dependents.

• I authorize the eye doctor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health care practitioners according to the HIPPA Privacy Laws.

• I understand that the patient’s health information is private and confidential. I understand that Eye Care One works very hard to protect the patient’s privacy and preserve the confidentiality of the patient’s personal health information. Eye Care One has a detailed document called the “Notice of Privacy Practices”. It contains more information about the policies and practices protecting the patient’s privacy and is available for your review and acknowledgment.