In the course of providing service to you, we create, receive, and store health information that identifies you. It is often necessary to use and disclose this health information in order to treat you, to obtain payment for our services and to conduct health care operations involving our office. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here, but also disclosures of your health information as may be necessary or appropriate for your to receive follow-up care for another health professional. 

I have read this document and understand it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations. 

ASSIGNMENT OF MEDICARE BENEFITS

Central Coast Optometric Center is a Medicare participating provider. Therefore, we will bill Medicare directly. Medicare will send payment directly to CCOC. This payment will consist of 80% of the Medicare part B approved charges. I understand that I will be responsible for the yearly deductible and 20% of approved charges. I have been informed that not all services are covered by Medicare (e.g. routine yearly eye exams and eye refractions). 

My signature below further verifies that I have not joined an HMO or other entity in which my Medicare benefits have been relinquished.