I have read and understand the information provided above. If declining the above tests, I understand that I am not allowing the physicians to conduct the most thorough examination of the eyes. This will decrease the ability to detect eye disease such as retinal detachments, glaucoma, etc.

I authorize Accent Eyecare to take any and all actions necessary to obtain payment from my insurance company, the Social Security Administration or other responsible party for any and all services provided to me by the doctor and staff of Accent Eyecare. Further, I assign any and all payments due from my insurance company, the Social Security Administration or other responsible party directly to this office. I realize that in the event that my insurance company or other responsible party erroneously sends payments owed to Accent Eyecare directly to me, those payments legally belong to Accent Eyecare. I realize that I must forward those payments immediately to Accent Eyecare. I understand that my signature below allows Accent Eyecare to release my confidential medical record to the insurance company, The Social Security Administration or other responsible party, in order to expedite payment of my claims. I further understand that any co-pays or deductible amounts not paid by my insurance company, The Social Security Administration, or other responsible parties, do become my responsibility. In addition, I understand that I am fully responsible for any costs associated with that collection process. I further understand that if after my claim has been submitted to my insurance company, Social Security Administration, or other responsible party, and it is then determined that I am not eligible; I am responsible for immediately paying the complete balance due. This authorization is effective for all appointments at Accent Eyecare.

By signing this acknowledgment of Receipt of Notice of Privacy Practices, 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 Accent Eyecare may use and disclose necessary personal health information to another party to permit us to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by Accent Eyecare (for example, mailings of exam reminders or information about services/products provided by Accent Eyecare). I can be assured that Accent Eyecare does not sell my personal health information to a third party ïoz said party’s own use. I acknowledge and agree that Accent Eyecare may submit my vision benefit claims to my health plan to receive reimbursement directly for the vision services and products that I have received.