15 & Under Form: Notice of Privacy Practice (HIPAA) Please Sign Both the Privacy Practices & the Payment Information Notice of Privacy Practice I acknowledge that I have read or have had the opportunity to read the Notice of Privacy Practices (available at the front desk). Patient Name First Last Date MM slash DD slash YYYY Signature of Patient or GuardianPayment Information Payment Information – Please read and sign below. Thank you I authorize you to bill my insurance for any applicable services or products. I understand that payments for noninsured services are due the same day services are rendered . I understand if I have not met my health insurance deductible and I’m receiving medical eyecare that 50% of the bill is due today, and any balance remaining after being processed through insurance will be billed to me. Signature of Patient or Guardian:Date MM slash DD slash YYYY We are glad to answer any questions regarding your insurance benefits. Thanks! Print this form
