Acknowledgement Form

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Erker’s Fine Eyewear

Insurance Signature On File

I certify that the information given by me in applying for insurance and/or Medicare/Medicaid payment is true and correct. I authorize my doctor to act as my agent in helping me to obtain payment of my insurance and/or Medicare/Medicaid benefits, and I authorize these payments directly to Erker’s Fine Eyewear on my behalf for any services received. I authorize any holder of medical information about me to release to the centers for Medicare and Medicaid Services and its agents any information needed to determine these benefits payable to related services. If I have other health insurance coverage my signature authorizes release of the above medical information to the insurer or agency shown, and authorizes my doctor to act as my agent, as above.

HIPAA Acknowledgement of Receipt

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 healthcare operations involving our office. The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. I acknowledge that I have received access to Notice of Privacy Practices from Erker’s Fine Eyewear.

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