Welcome Back Patient Form

Welcome Back!

Emergency Contact:

HIPAA POLICY: Please read carefully

I agree to allow my medical information be shared with my insurance company for the sole purpose of billing and to any healthcare provider necessary for continuity of care. I acknowledge that I am aware that Griswold Eye Care has a Notice of privacy practices available to me at all times during normal business hours. I fully understand that I am protected under HIPAA and will be required to sign a release for any and all medical records.

OFFICE POLICY: Please read carefully

In order to control the cost of billing we require that the patient’s portion of costs is due at the time of services rendered unless other arrangements are made in advance. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance.

All glasses sales are final and cannot be canceled or returned as they are all custom made. There will be a service charge on all returned checks. We require at least 24 hours notice for any cancellations or rescheduled appointments. Any late cancellations or missed appointments are subject to a $50 fee. I acknowledge and accept the above policies.