I hereby authorize the release of any medical information to process all claims, and request payment of any medical benefit to be paid to Sparks Eye Care LLC
Sparks Eye Care LLC
Rebecca Sparks, OD
307 W Highway 54, Suite 100
Andover, KS 67002
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA).
By signing the consent, I authorize you to use and disclose my protected health information to carry out: