AUTHORIZATION and RELEASE I authorize my insurance company to pay Eye Specialists benefits that would otherwise be payable to me. I understand that my insurance carrier may pay less than the actual bill for services. I also understand that I am responsible for all co-pays, deductibles, co-insurance and balances. I personally agree to pay for any and all services provided to me at the rates in effect during the time services are rendered. I understand and agree that my bill for services rendered is due and payable at the end of services and that I am ultimately responsible for any unpaid balances. By signing this authorization, I agree that this office, in any third party used for treatment, billing, collection and other services, may use any means of communication with me, unless i say otherwise. Thus, I understand that any phone numbers and email address provided by myself to eye specialists and to any of our service providers may leave messages to me manually and by using automated systems such as artificial or pre recorded voice. Specifically if I provide a cellar phone number, I consent and agree to accept collection calls and other communications to my cellar phone from this office and from any other service provider. I also agree that eye specialist and any other service providers can contact me by sending texts, emails to any phone number and email address provided to this office or service providers, and I consent to receive such text messages and emails which may identify the name of this office or service provider sending the communication, and which may disclose the nature of the communication.

HIPPA Privacy Policy Acknowledgement of Receipt I acknowledge that I was given the opportunity to receive a copy of Eye Specialists Notice of Privacy Practices.