Eye Clinic, LLC - Sedalia

Step 1 of 3

  • The Eye Clinic, LLC

    Dr. Kevin K.E. Carl - Dr. Desmon Carl
  • Assignment and Release

    I hereby authorize payment directly to Dr. Kevin Carl and/or Dr. Desmon Carl of all insurance benefits otherwise payable to me for the services rendered. I understand that I am financially responsible for alt charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents. I authorize Dr. Kevin Carl and/or Dr. Desmon Carl to release the information required to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
  • Date Format: MM slash DD slash YYYY
  • ONE TIME AUTHORIZATION

  • I request that payment of authorized Medicare benefits be made either to me or on my behalf to Dr. Kevin Car1amor Dr. Desmon ar for any services fiimished me by that physician. I authorize any holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agent any information needed to determine these benefits or the benefits payable for related services.
  • Date Format: MM slash DD slash YYYY
  • ACKNOWLEDGEMENT OF RECEIPT

    Our Privacy Practice policy is available for anyone who would like a copy, just inform the front desk if you would like a copy. Please sign below even if you choose not to receive a copy of our Privacy Practice policy. I acknowledge that I received a copy of Dr. Kevin Carl and/or Dr. Desmon Carl’s notice of Privacy Practices.
  • Date Format: MM slash DD slash YYYY