Privacy Policy
| Effective: | January 1, 2001 |
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AUTHORIZATION TO RELEASE INFORMATION: I/ WE hereby authorize InVision Eye Health to release any medical or incidental information that may be necessary for medical benefit or in processing applications for financial benefit. This includes but is not limited to my insurance company, Rehabilitation Services, Social Security Administration and Workers Compensation.
CONSENT FOR TREATMENT: I/WE hereby authorize the practice to administer diagnostic and medical procedures
as may be necessary for proper health care.
OFFICE POLICY ON PAYMENT: I understand that I am responsible for payment on all charges. As a courtesy,
my insurance will be billed for me. It is my responsibility to pay deductible, co pay or any other balance not paid
by my insurance company. I authorize insurance benefits to be paid directly to the provider.
HIPPA Privacy Policy: Our written Notice of Privacy Practices provides detailed information on how we may use and discloses protected health information. According to HIPPA provision, you have the right to receive and review a copy of this notice prior to signing this form.
[ ] I have read and understand the above policies, and Invision Eye Health’s Notice of Privacy Practices have been made available to me.
Signature : ________________________ Date:____________________
| Privacy Contact Officer: | Jennifer Pruetz |
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