Privacy Practices Form

I authorize Eye1st Vision Center to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Eye1st Vision Center insurance benefits otherwise payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I am the guarantor of this account, and I have read, understand, and agree to these office policies. Further, I acknowledge that I am familiar Eye 1st Vision Center Privacy Practices.