Privacy Notice
Insurance Release
I request the payment of authorized Medicare (and/or all other insurance or plans) benefits be made on my behalf to Ron Goldstein O.D. P.C., for services furnished to me by Ron Goldstein O.D. P.C. . I authorize any holder of medical information about me to be released to the center for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. accepts the charge determination of the Medicare carrier as the full charge, and I'm responsible only for the deductible, co-insurance and non- covered services. Co- insurance and deductible are based upon the charge determination of the Medicare.
Vision Plan Release
I hereby authorize this vision care provider to apply for benefits on my behalf for covered services rendered by them. I also assign my benefits and request that all payments from my vision plan be made directly to the vision care provider. I agree to assume responsibility of full payment pending any remaining balance that is not covered by my vision plan. I certify that the information that I have reported with regard to my coverage is correct. I further authorize this provider to release any information necessary to process my claims. If a medical problem is found to be the primary reason for my eye examination, then my medical insurance will be billed first and I will be responsible for any co-payment as required by my health insurance.
HIPAA Privacy ACKNOWLEDGEMENT OF RECEIPT and General consent
I acknowledge that I received a copy of Dr. Ron Goldstein's Notice of Privacy Practices.
I further consent to the release of my health information for purposes of treatment, payment, and health care operations and as authorized or required by law under the circumstances described in the Notice of Privacy Practices.
Patient name: ___________________________
Date of Birth: _________
Signature: ____________________________
Today's Date: ________, 2011_____________
Print Name: ________________
Guardian Signature: _____________________________
Date: __________
If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
Relationship to Patient: ___________________
Consumer information is not shared with third-parties for marketing purposes.
I request the payment of authorized Medicare (and/or all other insurance or plans) benefits be made on my behalf to Ron Goldstein O.D. P.C., for services furnished to me by Ron Goldstein O.D. P.C. . I authorize any holder of medical information about me to be released to the center for Medicare and Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance is indicated in Item 9 of the CMS 1500 form or elsewhere on other approved claim forms, my signature authorizes releasing the information to the insurer or agency shown. accepts the charge determination of the Medicare carrier as the full charge, and I'm responsible only for the deductible, co-insurance and non- covered services. Co- insurance and deductible are based upon the charge determination of the Medicare.
Vision Plan Release
I hereby authorize this vision care provider to apply for benefits on my behalf for covered services rendered by them. I also assign my benefits and request that all payments from my vision plan be made directly to the vision care provider. I agree to assume responsibility of full payment pending any remaining balance that is not covered by my vision plan. I certify that the information that I have reported with regard to my coverage is correct. I further authorize this provider to release any information necessary to process my claims. If a medical problem is found to be the primary reason for my eye examination, then my medical insurance will be billed first and I will be responsible for any co-payment as required by my health insurance.
HIPAA Privacy ACKNOWLEDGEMENT OF RECEIPT and General consent
I acknowledge that I received a copy of Dr. Ron Goldstein's Notice of Privacy Practices.
I further consent to the release of my health information for purposes of treatment, payment, and health care operations and as authorized or required by law under the circumstances described in the Notice of Privacy Practices.
Patient name: ___________________________
Date of Birth: _________
Signature: ____________________________
Today's Date: ________, 2011_____________
Print Name: ________________
Guardian Signature: _____________________________
Date: __________
If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form:
Relationship to Patient: ___________________
Consumer information is not shared with third-parties for marketing purposes.