1. Protected Health Information (HIPAA Disclosure)
I consent to the use and disclosure of my health information for purposes of treatment, payment and healthcare operations. I acknowledge that I have received and read the Notice of Privacy Practices from Drs. Hall & Szeto Optometry (click to read link) .
2. Insurance Signature on File
I certify that the information given by me in applying for insurance is true and correct. I authorize my doctor to act as my agent in helping me obtain payment of my insurance and I authorize payment of these benefits directly to Drs Hall & Szeto Optometry on my behalf. If I have other health insurance coverage my signature authorizes release of the above medical information to the insurer or agency, and authorizes my doctor to act as my agent as above.