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By signing this form I give Wendell Eye Care permission to release the following information to the individual or individuals listed below when requested. For Children under the age 18 parents/legal guardians will be entitled to this information. Any individual over the age 18 will need anyone they would like privileged to this information listed in order to gain access. This can include spouse, parents, child, caretaker, and etc. Anybody not listed will not be granted access to any information. Thanks, Dr. Lutz and Staff

We would like to thank you for choosing Wendell Eye Care to provide your eye care needs. We are committed to providing you with the best possible care. The following information is intended to provide you with an understanding of our financial agreement and billing procedures to prevent misunderstandings. As a courtesy to you, we may obtain eligibility and /or benefit information from your insurance company and communicate this information to you. We will also file a claim on your behalf for any services rendered, however, the patient or guarantor is ultimately responsible for understanding the specifics of his/her insurance plan and for the payment of all services rendered. Delinquent accounts: If the account is not paid in full or satisfactory arrangements made within the allowable time-frame, we reserve the right to refer the account to a collection agency for the collection of the balance. We understand temporary financial problems may affect timely payment of your balance. Any outstanding balances on the account must be paid before any services, including contact lens or glasses purchased. All copayments, coinsurance, deductibles, fees and outstanding balances must be settled at the time of service. The forms of payment we accept are cash, all major credit cards, and Care Credit. Sorry for any inconvenience this may cause. Your signature represents you have reviewed our Financial Policies and your acknowledgment of full financial responsibility for any services rendered, as well as your understanding and acceptance of our policies.

In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information to treat you, obtain payment for our services, and conduct healthcare operation involving our office. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. I acknowledge that I have received the Notice of Privacy Practices from Jonathan Lutz, O.D.