ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES: I acknowledge that I received a copy of Roggy Eye Clinic’s Notice of Privacy Practices.
NON-COVERED SERVICES: I understand that I am responsible for all fees that are not covered or reimbursed and will pay them within 30 days. I agree, in the event of non-payment, I will become responsible for the cost of interest, collection, and legal action.
AUTHORIZATION TO RELEASE INFORMATION: I authorize my insurance company to release information regarding my coverage to Roggy Eye Clinic. I authorize agents of any hospital or previous doctors to furnish Roggy Eye Clinic copies of any records of my medical history, services or treatments. I authorize the release of medical information and/or reports related to my treatment to any doctor, optical supplier, pharmacy, or insurance company as needed or requested by me. I also agree to review my records for purposes of internal audits, research, and quality assurance within Roggy Eye Clinic.
ASSIGNMENT OF BENEFITS: My right to payment for all procedures, tests, supplies, and technical/physician services including major medical benefits are hereby assigned to Roggy Eye Clinic. This assignment covers any and all benefits under Medicare, other government sponsored programs, private insurance and any other health plans. I acknowledge this document as a legally binding contract to collect my benefits as payment of claims for services. In the event my insurance company does not accept Assignment of Benefits, or if payments are made directly to me of my representative, I will endorse such payments to Roggy Eye Clinic.