I certify that I, and/or my dependent(s), have insurance/Medicare coverage and assign directly to
Ophthalmology Associates all insurance benefits, if any, otherwise payable to me for services rendered. I
understand that I am financially responsible for all charges whether or not paid by insurance. I authorize
the use of my signature on all insurance submissions.
Ophthalmology Associates may use and disclose my health care information to the insurance companies
and/or the Centers for Medicare and Medicaid Services, and their agents for the purpose of obtaining payment
for services and determining benefits or the benefits for related services.
IT IS YOUR RESPONSIBILITY TO INFORM US AT THE POINT OF SERVICE IF YOU HAVE
INSURANCE COVERAGE FOR ROUTINE EYE SERVICES.
HIPAA - Consent for Purposes of Treatment, Payment or Healthcare Operations
I understand that as part of my healthcare, Ophthalmology Associates creates and maintains health
records describing my health history. I understand that Ophthalmology Associates may use this information as:
I have been provided a Notice of Ophthalmology Associate's Privacy Practices, which provides a more
complete description of information uses and disclosures. I understand that I have the right to review the notice
prior to signing this consent. I understand that Ophthalmology Associates reserves the right to change its notice
and practices, and I will be provided a revised copy. I understand that I have the right to request restrictions as
to how my health information may be used or disclosed to carry out treatment, payment or other healthcare
operations, and that Ophthalmology Associates is not required to agree to the restrictions requested. I
understand that I may revoke this consent in writing, except to the extent that Ophthalmology Associates has
already taken action in reliance on it.
I hereby consent to the use, retrieval and disclosure of my personal health and pharmaceuticals
information by Ophthalmology Associates for purposes of treatment, payment and healthcare operations.
I give consent to Ophthalmology Associates to release any and all health care information and results to the persons listed below: