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Insurance & HIPAA Form


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  • I understand that the services I/my child receive will be billed to my insurance company as shown on the card I present at the time of my examination. I understand that my/my child’s medical records are confidential. I authorize the release of any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such care to third-party payers and/or other health care practitioners. I understand that I may revoke this consent by written request. I understand that I have the right to restrict the disclosure of specific information in my medical records if I request such restriction in writing. I also understand that my request may be denied if the information restricted is required for health care operations.

    I authorize and request my insurance company to pay directly to Maria Della Porta, O.D. insurance benefits otherwise payable to me. I also authorize Dr. Della Porta to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

    In the event that this claim is denied by my insurance company or applied toward my deductible, I agree to pay the full amount not covered within thirty days of such denial.

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  • Copies of our privacy policy are available at the time of your examination.

    I acknowledge that I have seen a copy of the Notice of Privacy Practices for Maria Della Porta, O.D.

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