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Diane King O.D.admin2017-07-06T01:14:32+00:00

Diane King O.D.

    *If YES, please provide any changes since your last visit.
  • *If this exam is for a minor, please provide responsible parent's email address.
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  • Due to changes in HIPAA Rules, we must now request the following additional information for our records.
  • I certify that I and/or my dependents have insurance coverage and assign benefits directly to Diane A. King, OD. I authorize use of my signatture on all claim submissions. Dr. King may use my health information and may disclose such information to the above named insurance company for the purpose of ontaining payment for services and/or for determining insurance benefits.
  • If you have vision coverage for routine eye examinations or medical coverage for problem visits with a company with which we have a contract AND you provide us with all information needed to file the claim, we will gladly accept contracted payment from the plan. If you notify us after services are received, we will supply you with a receipts you can submit to your plan. Please remember that it is your responsibility to ensure all referral and certification procedures are followed.
  • Co-payments and overages are due on the day of services are received and when materials are ordered, we accept cash, checks, and credit cards to aid you in budgeting expenses. If for any reason the account should become delinquent I agree to pay all billing charges, interest charges, collection costs and reasonable legal fees.
  • The Health Insurance Portability & Accountability Act of 1966 ("HIPAA") is a federal program that requires all medical records be kept confidential. As required by HIPAA, we have prepared a Notice of Privacy Practices Policy. A Copy of the policy is available upon request. By signing below, you acknowledge that this information has been made available to you.
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