By signing this acknowledgement of receipt of Privacy Practices (the "Notice"): I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my own records on the date identified below.

I understand that the Location may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit the Location to perform its administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by the location (for example, mailings of exam reminders or information about services/ products provided by the location).

I can be assured that this Location does not sell my personal health information of any kind to a third party for such party's own use.

I acknowledge and agree that the Location may submit my vision benefit claims to my plan sponsor or health plan to receive reimbursement directly for the vision services and products that I have received from the Location

Policies

• Please give the assistant your Health Insurance ID Card and Driver's License so that we may make a copy for the record. Although we may not be participating in your plan, we will assist you in obtaining reimbursement when applicable.
• Payment is expected when services are rendered and when eyeglasses and/or contact lenses are ordered. I understand that I am responsible for all services and/or materials ordered.
• I authorize Dr. Michael A. Benetatos NJ Lic#27OA00509800, to perform medical and diagnostic tests when indicated.
• In order to submit an insurance claim, we must have your authorization to release medical information to your insurance carrier(s). You are responsible for any coinsurance and/or deductible and referrals. As well as any non-covered services.
• In the event that my account becomes delinquent for more than 30 days, I also agree to pay a finance charge of 1.5% per month on any balance due, as well as all reasonable collection costs not to exceed 50%, court costs, attorney fees and interest fees accrued with the collection of the account.
• Refraction may not be covered by your medical insurance. You may be billed $45.00 for this service.
• If the insurance information you have provided at the time of service is incorrect, you will be responsible for payment.
• We reserve the right to bill a $25 fee for missed appointments or cancelations without a 24 hour notice.
• If your insurance company makes your glasses, we will NOT be held liable for any defects or warrantee them.

I authorize the release of any information and other information necessary to process my insurance claims. I also authorize payment of medical benefits to Michael A. Benetatos O.D. LLC. This authorization applies to all occasions until revoked. I have read and understand the HIPPA Privacy Notice.