HIPAA Release & Financial Policy

CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS EFFECTIVE 01/24/2011


I understand that as part of my health and medical care, Innovative Eyecare, PLLC, originates and maintains medical health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I further understand that this information serves as:


  • A basis for planning my care and treatment

  • A means of communication among health professionals who contributes to my care

  • A means of information for applying my diagnosis and treatment information to my bill

  • A means for a third-party payer to verify that services were billed as actually provided

  • And a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professions


I further understand and agree that this agreement to release information shall apply to all information accumulated to this date and any information acquired in the future. This agreement to release future information shall remain in force until such time as I shall revoke it in writing.


I understand and have been provided with a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the Notice of Privacy Practices prior to signing this consent. I understand that Innovative Eyecare, PLLC, reserve the right to change their notice and practices. If this notice is revised, I understand that I will be mailed a copy of any revised notice to the address I have provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that Innovative Eyecare, PLLC is not required to agree to the restrictions requested. I understand that I must revoke this consent in writing, except to the extent that Innovation Eyecare, PLLC has already taken action in reliance thereon.


By Oklahoma law we are required to notify you that the information authorized for release may include records which may include the presence of a communicable or non-communicable or venereal disease, which may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea and the human immunodeficiency virus, also known as Acquired Immune Deficiency Syndrome (AIDS).

First Name

Last Name

Date of Birth

In addition to the releases outlined above and in the Notice of Privacy Practices, information may be released to the following individuals:

I request the following restriction to the use and/or disclosure of my health information:

You may leave (appointment reminders or medical information) on my message service or machine.*

You may e-mail information to me. (example: appointment reminders).*

You may file my insurance on my behalf.*

You may fax information to other doctor’s offices or fax information to me.*

I certify by my signature that I am the patient signing on my own behalf or that I am the authorized representative signing on behalf of patient. (If authorized representative, please list your relationship to the patient)

​​​​​​​E-Signature*

Financial Policy


We would like to take the time to answer some question you may have regarding our financial policy. Communication is part of the commitment we have made to provide excellent patient service.

Payment: For all services, eyewear, accessories and contact lenses ordered or provided by the physicians and staff of Innovative Eyecare LLC, payment is due at the time of service. This includes your portion that insurance will not pay including any co-pay, deductible and co-insurance amounts. We accept Visa, Master Card and Discover for your convenience.

Returned Check Fee: $25.00

Insurance concerns: At each visit to our office, we will ask if you have had any changes to your insurance. If current information is not obtained at the time of service, it will become the patient’s responsibility to pay until current information is supplied. As a courtesy, we will bill your insurance company for the services provided to you. However, it is your responsibility to know the benefits and conditions of your insurance plan. Some procedures require pre-certification, a referral or an authorization before the service is performed. If you have a medical condition or suspect that you may have a medical condition concerning your eyes and your insurance requires any of the above, it is your responsibility to advise us at the time the appointment is made. If for some reason, your insurance company fails to pay, we will expect you to pay the balance in full. If you have not met the deductible amount for the current year and the insurance company applies our requested payment to your deductible, you will be billed for the full amount of the services. Payment will be required in full within 10 days of the date on the statement. (A $5 service fee will be added each month to any amount due that is older than 90 days.)

Collection of Balances Due: If you have an unpaid balance, a monthly statement will be mailed to you. If this balance is unpaid at 90 days, the unpaid balance is subject to be turned over to collection services.

Patients without insurance: Payment is due at the time service is rendered.

Questions: Thank you for taking the time to read our financial policy. We hope this answers your questions. If you have any other questions, please call our office at (405) 509-2100.

​​​​​​​I certify by my signature that I am the patient signing on my own behalf or that I am the authorized representative signing on behalf of patient. (If authorized representative, please list your relationship to the patient)

Date of Birth

E-Signature*

Date Effective*

Contact Info

Address: 1200 NW 178th St, Ste. 100 Edmond, OK 73012
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Phone: (405) 509-2100
4055092288