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Home » Acknowledgement of Notice of Privacy Practices – Custom Eyes Lee’s Summit (Custom Vision, Inc., DBA Custom Eyes)

Acknowledgement of Notice of Privacy Practices – Custom Eyes Lee’s Summit (Custom Vision, Inc., DBA Custom Eyes)

  • Date Format: MM slash DD slash YYYY
  • INSURANCE INFORMATION

    I, the undersigned have insurance coverage as mentioned below and assign directly to Drake & Associates, Optometrists, P.A., DBA Custom Eyes all medical and vision benefits, if any, otherwise payable to me, for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all of my insurance submissions.

    MEDICAL INSURANCE

  • VISION INSURANCE

  • I ACKNOWLEDGE THAT I ACCEPT RESPONSIBILITY FOR ALL INSURANCES CHARGES NOT PAID.


    I have read and understand this form. I am signing it voluntarily.
  • Date Format: MM slash DD slash YYYY
  • If you are signing as a personal representative of the patient, please indicate your relationship

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