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ACKNOWLEDGMENT
OF
NOTICE OF PRIVACY PRACTICES
Please click on the blue underlined link below to view the ACKNOWLEDGMENT
OF
NOTICE OF PRIVACY PRACTICES.
View ACKNOWLEDGMENT
OF
NOTICE OF PRIVACY PRACTICES
The law requires that Kara Fedders, OD, P.C. make every effort to inform you of your rights related to your personal health formation. By signing below, I acknowledge that:
I have read or had explained to me prior to any services offered Kara Fedders, OD, P.C.'s Notice of Privacy Practices and agree to continue my care with Kara Fedders, OD, P.C. under said terms.
I was given the opportunity to read Kara Fedders, OD, P.C.'s Notice of Privacy Practices and declined, but wish to continue my care with Kara Fedders, OD, P.C. said terms.
I have read or had explained to me prior to any services offered Kara Fedders, OD, P.C.'s Notice of Privacy Practice and disagree to continue my care with Kara Fedders, OD, P.C. under said terms.
The Notice of Privacy Practices could not be read due to the emergent nature of the care of other reasons describes as:
I HAVE READ AND UNDERTSAND THIS FORM. I AM SIGNING IT VOULUNTARILY.
Patient Signature:
Date:
If you are signing as a personal representative of the patient then please indicate your relationship.
Representative
Relationship To Patient
SIGNATURE ON FILE FORM
RESPONSIBILITY STATEMENT
Your insurance is a method for you to receive reimbursement for fees you have paid to the optometrist for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowance or percentages based on your contract with them, not with our office. It is your responsibility to pay in advance for the deductible, coinsurance, or any other balances not paid for by your insurance. We will assist you in receiving your reimbursement as much as possible, but you are responsible in advance for your bill.
FINANCIAL RESPONSIBILITY
By signing this statement you agree to be financially responsible for all charges.
AUTHORIZATION TO RELEASE MEDICAL INFORMATION
I authorize any holder of medical information about me to release Heath Care Financing Administration and its agents any information needed to determine benefits or the benefits payable to related services. This assignment will remain in effect until it is revoked in writing. A photocopy of this assignment is considered to be as valid as the original.
Patient Signature:
Date: