Acknowledgment of Notice of Privacy Click to Read Our Privacy PolicyThe law requires that Parkland Eye & Vision Clinic, PLLC make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that: I was given the opportunity to read, have read or had explained to me Parkland Eye & Vision Clinic, PLLC's Notice of Privacy Practice prior to any services offered. The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible I authorize Parkland Eye & Vision Clinic, PLLC to release my personal health information to the following individuals: Name First Last PhoneName First Last PhoneName First Last PhoneMy vision plan and or medical plan requests that all diagnoses related to any medical condition I may have be released to them. As a non-traditional disclosure, release of this information requires my specific authorization: I authorize the release of medical information to my vision plan and or medical plan I do not authorize release of medical information to my vision plan and or medical plan I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILYPatient Signature*Date Date Format: MM slash DD slash YYYY If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor.Representative Signature Relationship to PatientDate Date Format: MM slash DD slash YYYY Financial PolicyInsurance Parkland Eye & Vision is not responsible for charges NOT covered by your insurance company. Insurance cards must be presented along with necessary forms at time of appointment We cannot guarantee the accuracy of information given by insurance companies regarding coverage. It is the patient’s responsibility to determine whether insurance company covers services rendered. We will bill your insurance if we are a participating provider for your program. We may bill your vision, medical insurance or multiple plans depending on coverage policies and your vision or medical condition(s). If we are not a participating provider, upon payment at time of service, you will be provided with paperwork to submit to your insurance company for reimbursement. You will be billed for all charges not reimbursed by your insurance company. Deductibles, co-payments and non- covered professional services or materials are due at the time of service or when materials are ordered. Payment Payment is due in full at time of service. We accept cash, check, Visa and MasterCard. Payment for all prescription devices, lenses, contact lenses and materials must be made beforeorders are placed. Orders are processed at time of full payment. Order cancellations must be made before close of that business day. Cancellations after this time are subject to charges. Eyeglasses are custom ordered per patient and therefore all frame sales are final and cannot be exchanged or refunded. Account balances over 30 days will receive a finance charge of 1.0% per month (12% APR). Checks returned for insufficient funds will incur a fee of $40 in addition to the amount due. Accounts not paid in full within 150 days are automatically placed with an outside collection’s agency I understand that I am responsible for the balance on my account for services rendered and/or materials purchased. If delinquent balances are referred for collection, I agree to pay all costs and attorney’s fees. I authorize that my insurance payments are paid directly to Parkland Eye & Vision. I authorize use of this signature on all insurance claims. I also authorize release of records to my insurance company as needed. I have read and agree to the Financial Policy of Parkland Eye & Vision Clinic, PLLC. This agreement remains in effect until revoked by me with written notification to Parkland Eye & Vision Clinic, PLLC Signature*Print Name First Last RelationshipDate Date Format: MM slash DD slash YYYY
