Medical Release Form Acknowledgement of Financial ResponibilityI authorize my insurance benefits be paid directly to Bowers Optometry PA, on my behalf. I also authorize Bowers Optometry PA, or my insurance company to release any information needed to process my claims. I understand that I am financially responsible for any co-pays, co-insurances, deductibles and other non-covered services or materials on the day services are rendered. I also understand that I am financially responsible for any balance remaining after my claim has been processed.Initial*Patient Privacy Informed ConsentI have been informed and I consent to the release of my medical information, in compliance with HIPAA regulations. My medical information will only be released to other medical providers for continuity of care, and to insurance companies to have my medical claims reimbursed. Bowers Optometry PA practices a minimum information disclosure policy and only necessary information will be forwarded to these entities. I understand that Bowers Optometry PA reserves the right to change their Privacy Notice and make changes effective for all personal health information they may already have, and they will provide me with a revised copy. I authorize Bowers Optometry PA, Kimberly Bowers OD, and her staff to release my health information for these purposes.Initial*Office PoliciesWe request 24 hours' notice to cancel or reschedule an appointment. We understand that emergencies do come up; please call our office as soon as possible if you cannot keep your appointment so that other patients in need of care can be seen. We do charge $25 if less than 24 hours' notice is given or you do not show up for an appointment.Initial*Email ConsentI consent to have prescriptions and invoices emailed to me even though they may contain personal health information. I consent:* Yes No Medical Release ConsentI authorize disclosure of information regarding my billing, condition, treatment and prognosis to the following individuals:Name First Last Relationship Name First Last Relationship Name First Last Relationship Signature*Printed Name* First Last Date MM slash DD slash YYYY
