Signature Form

Financial Policy

I have read and understand the Financial Policies of The Vision Source-Kingwood, P.A. and also understand that The Vision Source-Kingwood, P.A. reserves the right to change any and all fees at any time. I also understand ALL copayments and additional charges are due before I leave on the date the charges are incurred.

Signature of Patient (or Responsible Party if Patient is a Minor & Relationship)

Date

Consent To Treat

I have read and understand the Consent to Treat form. I consent to the treatment provided to me by Vision Source-Kingwood, P.A., its doctors and employees.

Signature of Patient (or Responsible Party if Patient is a Minor & Relationship)

Date

The law requires that we make every effort to inform you of your rights related to your personal health information.

I do authorize The Vision Source-Kingwood, P.A. to leave a message with available persons, on my answering machine or with contacts listed below on the Patient Approved list.

Yes No

I do authorize The Vision Source-Kingwood, P.A. to leave a message at my place of employment.

Yes No

By my signing below, I acknowledge that: I have read or had explained to me, prior to any services offered, Vision Source Kingwood’s Notice of Privacy Practice and agree to continue my care with Vision Source Kingwood under said terms.

Signature of Patient (or Responsible Party if Patient is a Minor & Relationship)

Date

Patient Authorization for Access to Protected Health Information

I grant permission for the following persons to have access to my Protected Health Information:

Person’s Name

Relationship to Patient

Please note that this form will stay in effect until you, the patient, have provided us with written termination of any changes of any of the persons on this list or you, the patient, request to complete a new form in which the previous form with be considered void. You may change this form at any time you choose and as many times as you choose.

Signature of Patient (or Responsible Party if Patient is a Minor & Relationship)

Date

Vision Source Kingwood, P.A. would like to provide your PCP (Primary Care Physician) with a detailed report of your eye exam findings to help keep your PCP updated on all aspects of your health care. Please provide your PCP’s information below.

Primary Care Physician

Phone Number

Address

Fax Number

Your information will be encrypted.