ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES The law requires that Michael Bollish, O.D., P.C. make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that I have read or had explained to me Michael Bollish, O.D., P.C.’s Notice of Privacy Practice and agree to continue my care with Michael Bollish, O.D., P.C. under said terms.I was given the opportunity to read Michael Bollish, O.D., P.C.’s Notice of Privacy Practices and declined but wish to continue my care with Michael Bollish, O.D., P.C. under the terms of Michael Bollish, O.D., P.C.’s privacy policies.I have read or had explained to me Michael Bollish, O.D., P.C.’s Notice of Privacy Practice and do not wish to continue my care with Michael Bollish, O.D., P.C. under said terms.The Notice of Privacy Practice could not be read due to the emergent nature of the care of other reason described asI HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. Patient First Last Date Date Format: MM slash DD slash YYYY If you are signing as a personal representative of the patient, please indicate your relationship RepresentativeRelationship to PatientUntitled Knowing that standard email and text communication may not be totally secure, I still consent to communication from my doctor or staff through my standard email and texting devices. (Check the box if you consent). PATIENT FINANCIAL RESPONSIBILITYI hereby authorize Michael Bollish, O.D., P.C. to apply for benefits on my behalf for covered services rendered. I also assign my benefits and request that all payments from my insurance company be made directly to Michael Bollish, O.D., P.C. I agree to assume responsibility of full payment pending any remaining balance that is not covered by my insurance company. I certify that the information I have reported with regard to my coverage is correct. I further authorize Michael Bollish, O.D., P.C. to release my insurance company and its agents any information related to this or any related claim SIGNATUREPatient Name First Last Signature of PatientIf Patient is a Minor, Printed name and signature of Responsible Person (Parent or Guardian)nameSignatureDate Date Format: MM slash DD slash YYYY Our office utilizes American Credit Bureau, Incorporated for collections assistance. There is a $5.00 re-billing fee if we have to send you a second notice. A collection fee of $9.95 will be assessed if we have to report you to the credit bureau. There is a $4.95 address search fee if needed for collection purposes.
