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STEP 3 : Acknowledgment of Notice of Privacy Practices

  • Acknowledgment of Notice of Privacy Practices
    Lake Havasu Family Eyecare
    2277 Swanson Ave Suite 100
    Lake Havasu City Arizona 86403
    928-855-5026


  • I authorize Lake Havasu Family Eyecare to release my personal health information to the following individuals:

  • ASSIGNMENT AND RELEASE
    I certify that I, and/or my dependent(s), have insurance coverage and assign directly to Lake Havasu Family Eyecare all insurance benefits (including Medicare and government benefits), otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. I authorize the release of my health care information to the insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.
    I acknowledge that I am financially responsible for my account and/or dependents accounts. I agree to keep my account in good standing and pay all balances due. Should it become necessary, I agree that LHFE can send my bad debts to a collection agency and I am responsible for any fees assessed by that agency.

    I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
  • Date Format: MM slash DD slash YYYY
  • If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor.