Receipt of Privacy Notice

I hereby acknowledge that I am aware of the HIPAA Privacy Notice that explains how my health information will be handled in various situations. I understand that I am able to request a copy of this notice, or discuss any questions I may have regarding the privacy notice with my provider, and I am aware that federal law requires that a signed copy of this form be retained with my electronic Personal Health Information file.

Release of Information

I hereby authorize Miller Optometry, Inc. to release to my insurance company and/or associated professionals any information from my medical record, which may be necessary to determine benefits payable under my policy.

Assignment of Benefits

Please provide all insurance cards (both medical and vision) to our staff at the time of your visit.

I authorize Miller Optometry, Inc. to act as my agent in obtaining payment from my insurance company, and authorize payment of said benefits directly to Miller Optometry, Inc. I understand I am financially responsible for any charges not covered by my insurance and/or settled by my claim.

Agree with everything you see?

By signing in the box below, you acknowledge receipt of our HIPAA Privacy Policy, grant permission for us to release selected medical information for purposes of payment, and assign Miller Optometry to act as your agent in obtaining payment from your insurance company.