Submit Data / Patient Signatures
Please click on the blue links below, read carefully and sign your acceptance by entering your First and Last Name in the boxes below.
Notice of Privacy
View Notice of Privacy
The law requires that Kara Fedders, OD, P.C. make every effort to inform you of your rights related to your personal health information. 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. under 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 UNDERSTAND THIS FORM. I AM SIGNING IT VOULUNTARILY.
If you are signing as a personal representative of the patient then please indicate your relationship.
Relationship To Patient:
SIGNATURE ON FILE FORM
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 allowances 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.
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.