Eye Rx – Financial, HIPAA & Consent Policy (One-Page)

Patient name *

First

Last

Date of birth *

Day

Month

Year

Guardian (if applicable)

Please initial each item to acknowledge your agreement.

Initials: Consent for examination and treatment *

I authorize the doctors and staff of the office to perform eye examinations, diagnostic testing, and treatment as medically appropriate.

Initials: HIPAA acknowledgement *

I acknowledge receipt of the Notice of Privacy Practices and understand how my health information may be used and disclosed. (add link)

Initials: Financial responsibility acknowledgement *

I understand I am financially responsible for all charges not covered by my insurance and that verification of benefits is not a guarantee of payment.

Initials: Assignment of benefits acknowledgement *

I authorize payment of medical and/or vision insurance benefits directly to the office and release of information needed to process claims.

Initials: Diagnosis based billing acknowledgement *

I understand that billing of my medical and/or vision insurance will be determined by reason for visit and clinical findings - not by patient preference.

Initials: No-show / cancellation acknowledgement *

I understand missed or late-cancelled appointments may result in a fee not covered by insurance.

Initials: Communication consent *

I authorize contact by phone, voicemail, text, and email regarding appointments, results, billing, and care coordination.

Initials: Eyewear and materials policy acknowledgement *

I understand custom eyewear and specialty lens products are non-refundable once ordered, except as required by law.

Signature *

Date signed *

Day

Month

Year