Patient Information Form

In the event that it becomes necessary for us to release your records to or request from another healthcare professionai, I authorize Optic Gallery to release and/or request these records. If applicable, I request payment of authorized Medicare or other insurances be made either to me or on my behalf to Optic Gallery, for any service rendered to me. i authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies.

I UNDERSTAND THAT I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY

It is the policy of this office to require: (1) Payment in fullor at least one-half deposit made before an order can be placed. (2) The balance of the fee must be paid at the time the order is dispensed. (3) All orders are final when placed. I furthur acknowledge and agree that all accounts past 30 days shail bear a compounding interest rate of 1.5% per month. I also acknowledge and agree that in the event I do not pay for services rendered "Optic Gallery" may place my account with a collection agency. I agree to pay reasonable collection fees, attorney fees and court cost incurred in collection of my overdue account.
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Signing in this section signifies that you have received a copy of our Notice of Privacy Practices.

In the course of providing service to you, we create, receive and store health information that identifies you It is often necessary to use and disclose this health information in order to treat you, to obtain payment for these services, and to conduct healthcare operations involving our offices.

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail.

I give permission to be in contact via text message or e-mail.