Signature On File Form & Authorization To Release Medical Information printable pdf download

Signature On File Form & Authorization To Release Medical Information

Signature on File Form

• RESPONSIBILITY STATEMENT •

Your insurance is a method for you to receive reimbursement for fees you have paid to

the optometrist for services rendered. Having insurance is not a substitute for payment.

Many companies have fixed allowances or percentages based on your contract with them

not with our office. It is your responsibility to pay in advance for the deductible, coinsur-

ance, or any other balances not paid for by your insurance. We will assist you in receiving

reimbursement as much as possible, but you are responsible in advance for your bill.

• FINANCIAL RESPONSIBILITY •

By signing this statement you agree to be financially responsible for all charges.

• AUTHORIZATION TO RELEASE MEDICAL INFORMATION •

I authorize any holder of medical information about me to release to the Health Care

Financing Administration and its agents any information needed to determine benefits

or the benefits payable for related services. This assignment will remain in effect until

revoked in writing. A photocopy of this assignment is considered to be as valid as the

original.

Patient Signature______________________________________ Date______________

Witness _____________________________________________ Date______________

Signature On File Form & Authorization To Release Medical Information