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HIPAA & Signature on File Form

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Acknowledgement of Receipt of Notice of Privacy Practices*
A copy of this office’s Privacy Practices is available upon request.

Signature On File Form For Third Party Billing

I request that payment of authorized insurance benefits be made either to me or on my behalf to the Doctors of Nittany Eye Associates for any services furnished to me by that physician/supplier. I authorize any holder of hospital or medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine the benefits payable for related services.

I permit a copy of this authorization to be used in place of the original, and request payment of Medical Insurance benefits either to myself or to the party who accepts assignments.

This field is for validation purposes and should be left unchanged.