Consent for Treatment

I, by my agreement below, grant permission for Heaton Eye Associates to render such care that the physician may deem appropriate in my treatment and diagnosis. I agree to my eyes being dilated if the doctor determines it is necessary.

I have read the Notice of Privacy Practices and have had all my questions answered by this office. I understand that by my acknowledgment of the terms indicated below, I consent to the following:

• Sharing information for the purpose of treatment: My health information
  may be used by Heaton Eye Associates or disclosed to other health care professionals
  for the purpose of evaluating my health, diagnosing medical conditions, coordinating
  and providing treatment.
• Sharing information for the purpose of payment: My health information
  may be used to seek payment from my health plan, from other sources of coverage
  such as an automobile insurer, or from credit card companies that I may use
  to pay for services.
• Sharing information for the purpose of operation: My health information
  may be used as necessary for business purposes to support the day-to-day operations
  of Heaton Eye Associates (including but not limited to the credentialing process,
  peer review, accreditation and compliance with all federal and state laws).

I hereby assign my health plan benefits or other applicable insurance benefits for medical/surgical treatment for myself to Heaton Eye Associates.

I understand and agree that I am responsible for compliance with the standards and regulations set forth in my health care plan and further understand that I will be responsible for all deductibles, non-reimbursable fees or fees for service not covered by my health care plan.

My consent is freely given. I understand that I may revoke this consent at any time if that revocation is in writing. Any use or disclosure that has already occurred prior to the date of my revocation of consent will not be affected.