DEMO/HIPAA ONLY

Privacy Policies and Consent Forms
Notice of Privacy Practices and HIPAA Agreements
I acknowledge that I received a copy of William H. Stephen, O.D. Notice of Privacy Practices.
Patient Authorization to Disclose Protected Health Information. HIPAA policy prevents our office sharing your protected heath information (PHI) with anyone other than yourself without your consent. If you would like someone other than yourself to have access to your health record, please include their name below.
Office Policies
I have read and understand the office policies of St. Lucy's Vision Center.
St. Lucy's Vision Center Finance Agreement
I authorize this office to release any information necessary to expedite insurance claims. I authorize use of signatures on this form for insurance claim submissions. I authorize payment directly to my doctor. I understand that I am responsible for all charges, regardless of insurance coverage. All accounts past 60 days are subject to 1 ½ % finance charge – annual rate 18%.