BY SIGNING THIS FORM, I AM CONSENTING TO TUCSON EYE PHYSICIAN’S USE AND DISCLOSURE OF MY PROTECTED HEALTHCARE INFORMATION FOR THE PURPOSE OF CARRYING OUT TREATMENT, FILING INSURANCE FOR PAYMENT AND HEALTHCARE OPERATIONS. I HAVE READ, BEEN OFFERED AND/OR PROVIDED A COPY OF TUCSON EYE PHYSICIANS NOTICE OF PRIVACY PRACTICES.
I HEREBY AUTHORIZE AND DIRECT PAYMENT TO TUCSON EYE PHYSICIANS, FOR ANY SURGICAL AND/OR MEDICAL BENEFITS, OTHERWISE PAYABLE TO ME UNDER TERMS OF MY INSURANCE. I ACKNOWLEDGE THAT I AM FINANCIALLY RESPONSIBLE FOR NON-COVERED SERVICES OR EXPENSES INCLUDING REFRACTIONS. I HEREBY AUTHORIZE PHOTO COPIES OF THIS FORM TO BE VALID AS THE ORIGINAL.
WE WILL BE HAPPY TO DISCUSS ANY QUESTIONS YOU MAY HAVE REGARDING YOUR BILL. PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE.
I HAVE READ THE ABOVE AGREEMENT AND UNDERSTAND IT.
