Acknowledgement of Notice of Privacy Practices

Name: Lee’s Summit
Address: 3660 NE Ralph Powell Rd, Lee's Summit, MO, 64064, US
Telephone: 816-524-7400
Price range: $000 - $300

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Patient Name
First Last
Date of Birth
MM slash DD slash YYYY
The law requires that Drake & Associates, Optometrists, PA, DBA Custom Eyes make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that:
- I was given the opportunity to read, have read or had explained to me Drake & Associates, Optometry, PA’s Notice of Privacy Practice prior to any services offered.
- The Notice of Privacy Practice could not be read due to the emergent nature of the care and will be acquired when possible.
I authorize Drake & Associates, Optometry, PA to release my personal health information to the following individuals
Our office may use standard email to communicate with you. Standard email is not secure and does not guarantee privacy.
- I authorize the use of standard email, in spite of the known risk involved, to communicate with me.
- I do not authorize the use of standard email to communicate with me.
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
Primary Insured
Primary Insured Date of Birth
Medical Insurance Company
Insurance Policy Information
VISION INSURANCE
Primary Insured
Primary Insured Date of Birth
Medical Insurance Company
Insurance Policy Information
I ACKNOWLEDGE THAT I ACCEPT RESPONSIBILITY FOR ALL INSURANCES CHARGES NOT PAID.

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

Acknowledgement of Notice of Privacy Practices

INSURANCE INFORMATION

MEDICAL INSURANCE

VISION INSURANCE

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

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Lee’s Summit

Lenexa

INSURANCE INFORMATION

MEDICAL INSURANCE

VISION INSURANCE

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

Ask Here, Voice Search

Lee’s Summit

Lenexa

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