HIPPA Notice / Assignment of Benefits / Signature on File / Financial Agreement
HIPPA NOTICE OF PRIVACY PRACTICES: I acknowledge that I received the Notice of Privacy Practice issued by Premier Vision Care that was effective April 1, 2005.
RELEASE OF INFORMATION: Premier Vision Care may disclose all or part of my medical record and/or financial ledger, including information regarding alcohol or drug abuse, pychiatric illness and communicable dieasese to any person or corporation (1) which is or may be liable or under contract to Premier Vision Care for reimbursement for services rendered and (2) health care providers for continued patient care. A copy of this authorization my be used in place of the original.
NON-COVERED SERVICES: I understand that Premier Vision Care’s contract with health care service plans (i.e. HMO, PPO), relate only to items and services which are “covered” by the health care service plans. Accordingly the person signing this documents accepts full financial responsibility for all items or services which are determined by the health care service plans as non-covered services.
FINANCIAL AGREEMENT: I agree that in return for services provided to me by Premier Vision Care, I will pay my account at the time the service is rendered. If my account is sent to a collection agency, I agree to pay collection expenses and reasonable attorney fees as established by the court and not by a jury in any court action. I understand and agree that if my account is delinquent, I may be charged interest at the legal rate. Any benefits of any type under any policy of insurance are hereby assigned to Premier Vision Care. If co-payments and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Premier Vision Care. I understand that I am primarily responsible for the payment of my bill.
INSURANCE: I authorize payment of my vision, medical and surgical insurance benefits to Premier Vision Care. I understand that I am financially responsible for any charges whether or not paid by said insurance. If co-payment and/or deductibles are designated by my insurance company or health plan, I agree to pay them to Premier Vision Care.
MEDICARE: I request that payment of authorizezd Medicare benefits be made on my behalf to Premier Vision Care, for services furnished to me by Premier Vision Care. I authorize any medical information about me released to the Centers for Medicare and Medicaid Services and its agents to determine benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorize the release of medical information necessary to pay the claim. If another health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. Premier Vision Care accepts the charge determination of Medicare carriers as the full charge and I am responsible only for the deductible, co-insuranc and non-covered services. Co-insurance and deductibles are based upon the charge determination of the Medicare carrier.
MEDIGAP: I understand that if a Medigap policy or other health insurance is indicated in Item 9 of the HCFA 1500 form or elsewhere on other approved claim forms, my signature authorizes release of the information to the insurer or agency shown. I request that payment of authorized secondary insurance benefits be made on my behalf to Premier Vision Care if possible or otherwise to me.
TEXT MESSAGE CONSENT: I authorize Premier Vision Care to contact me by SMS text message for health related notifications, prescriptions, appointment and yearly reminders, billing and insurance questions. I understand message/data rates may apply to messages sent under my cell phone plan. I am under no obligation to authorize Premier Vision Care to send me text messages. I may opt-out of receiving by calling 281-436-1757. I indicate I am the person legally responsible for all use of mobile accounts, that I am at least 18 years of age, and that I agree to all terms and conditions of use for the text messaging services.
CONSENT OF ELECTRONIC SIGNATURE: By selecting the consent box below and entering my name, I agree my electronic signature is the legal equivalent of my handwritten signature on this agreement and consent to the legally binding terms of this agreement. I further agree that my signature on this document is as valid as if I signed the document in writing. I agree that no third party verification is necessary to validate my E-signature.
