This will need to be signed in-person to activate
Acknowledgment of Receipt of Privacy Notice
By Signing this acknowledgement of Receipt of Notice of Privacy Practices (the “Notice”); I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that Bella Eye Care may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit Bella Eye Care to perform its administrative duties, provide me with eye care services and products, process my vision (and/or medical) benefit claims and communicate with me regarding vision care services provided by Bella Eye Care (for example, mailings of exam reminders or information about services/products provided by Bella Eye Care). I can be assured that Bella Eye Care does not sell my personal health information of any kind to a third party for such party’s own use. I acknowledge and agree that Bella Eye Care may submit my vision and/or medical benefits claims to my plan sponsor or health plan to receive reimbursement direction for the vision services and products I have received from the Bella Eye Care. Patient Agreement: I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance of my account. I understand that if for any reason my insurance company denies payment for services rendered I am responsible for payment in full. I authorize the release of any pertinent information for claims to be processed. I allow this to be used for Signature on File. ALL PROFESSIONAL FEES ARE NON-REFUNDABLE. ALL CONTACT LENS CHECK/FOLLOW UPS AFTER 90 DAYS ARE $35.
The patient’s portion must be paid at the time services are rendered. The undersigned will ultimately be responsible for any bill incurred in this office. Insurance verification is not a guarantee of payment by your insurance/vision plan. There will be a service charge on all returned checks. By signing below, I state that I have read and understand the Notice of Privacy Practices for this office. I authorize Bella Eye Care Optometry to release and obtain any medical records for the specified individual to the insurance provider and/or co-managed practitioner if necessary.