Assignment and Release Form "*" indicates required fields Assignment and ReleaseI certify that I, and/or my dependents have insurance coverage with ___________ and assign directly to Dr. Shrayman all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submission. Name First Last SignatureDate MM slash DD slash YYYY Notice of Privacy PracticesDr. Shrayman is required by law to protect certain aspect of your health care information and to provide you with a Notice of Privacy Practices. The notice describes our privacy practices, your legal rights and lets you know how Dr. Shrayman is permitted to: Use and disclose PHI about you How you can access and copy information How you may request amendment of that information How you may request restrictions on your use and disclosure of your protected health information The notice is available for you at the front desk. Please sign that you have received and reviewed its contents.Name* First Last Signature*Date* MM slash DD slash YYYY Consent for DilationA comprehensive eye examination includes pupillary dilation in order to better view the back of the eye (the retina). Dilation requires instilling drops into the eyes which will dilate the pupils, causing sensitivity to light and near vision blur that will last for several hours. You may do this today, reschedule for a time that is more convenient for you, or decline the procedure done. There is no extra charge for this procedure. I have been informed of the risks/benefits of dilation and* DO want a dilated eye exam today. DO NOT want a dilated eye exam today. Name First Last Signature*Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
