I authorize Georgia Eye, LLC to release medical records to any insurance company with whom I have medical or vision benefits, or to my employer, for the purpose of filing medical claims. I also authorize any physician, hospital, or clinic to provide medical information required in the course of my examination or treatment. I give consent for Georgie Eye, LLC physicians to obtain prescription history from external sources.

I consent to medical treatment for myself or for the patient for whom I am the parent or legally authorized representative.

Insurance is filed as a courtesy. It is the patient/guardian responsibility to ensure all bills are paid. All co-pays, deductibles, and co-insurance are due at the time or services. Surgical estimates are due a week prior to surgery.

Assignment of Benefits Payment: I authorize my health insurance benefit plan to pay directly to Georgia Eye. I understand that I am financially responsible for any non-covered charges. If I am a self-pay patient, I understand that I am responsible for all charges in full at the time of service. I have read and understood the Financial Policy terms and conditions effective 1/2/2020.

I acknowledge I have received the Notice of Privacy Practices and Notice of Individual Rights. Georgia Eye may release information to the following people: