Are YOU currently being treated for or have any of the following?
By signing below, you agree to the terms of the above financial policies:
Insurance Authorization and Release
I hereby authorize the release of any medical or other information necessary to process my insurance claim. I authorize payment of benefits directly to Horvath Vision Care, Inc. I understand that I am responsible for any deductible, copay, share of cost, or service not covered by my insurance.
Notice of Privacy Practices
We participate in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We, and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying our front desk staff.