HIPAA Authorization & Release of Medical Information
I authorize release of any information concerning myself, or my child's health care, advice, and treatment provider for the purpose of evaluation and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me, be made directly to the doctor(s) today and in the future. I acknowledge that I was offered/received a copy of American Eyecare's Notice of Privacy Practices. (If patient is under guardianship, legal guardian should sign as well.)