Financial and Privacy Policy Acknowledgement Form

Insurance Authorization and Assignment: I request that payment of authorized private insurance company benefits, Medicare, and other applicable benefits be paid on my behalf to Hawkin Lui, OD, A Professional Corporation, doing business as Optometry Corner, for any services rendered. I authorize Optometry Corner to release any medical or other information about me to any private insurance company, Medicare, and other insurance companies and its agents, which provide coverage to me.

Patient Responsibility: Optometry Corner will help bill my insurance company for materials and services rendered. However, payment for all services and materials are ultimately the responsibility of the patient. I understand that insurance benefits must be determined prior to my exam and that eligibility verification does not guarantee coverage once a claim is filed. I agree to personally submit the claim to my insurance company for reimbursement should I become aware of insurance coverage after services have been rendered. I also understand and acknowledge that I am financially responsible for non-covered services and any unpaid balance over 30 days is past due.

Payments, Co-pays, and Deductibles are due at time of service: I understand that not all services and materials may be covered by my insurance or may exceed benefits or coverage. I agree to pay all payments, co-pays, and deductibles at the time of service for all materials and services rendered, unless otherwise permitted by Optometry Corner.
Patient's Name:
First Last
Parent/Guardian (if not patient above):
First Last
Signature:
This signature will remain on file and effective from the above date.
Date:
MM slash DD slash YYYY
Acknowledgment of Receipt of Privacy Notices

Please sign below to indicate that you have been offered a copy of our Privacy Policy as the law requires us to do. Your signature does not indicate you have given up any rights or agreed to any special uses of your health records. It acknowledges that you were offered a copy of our Privacy Policy, which can be found posted in our office or on our website at www.OptometryCorner.com
Signature:
Date:
MM slash DD slash YYYY

Optometry Corner