I hereby authorize employees and agents of The Retina Group of Washington, PLLC (“RGW”) dba The Retina Care Center, an Affiliate of PRISM Vision Group, including physicians, physician assistants, nurse practitioners and other employees and staff members to render medical evaluations and care to the patient indicated below. The duration of this consent is indefinite and continues until revoked in writing. I understand that by not signing this consent, the patient will not be provided medical care except in the case of an emergency.

I hereby authorize The Retina Group of Washington, PLLC (“RGW”) dba The Retina Care Center, an Affiliate of PRISM Vision Group, to apply for benefits on my behalf and for payment of medical benefits directly to RGW for services rendered. I request payments of Medicare, Medigap and/or any other insurance company to be made directly to RGW. Authorization is hereby granted to release information contained in the patients’ medical record or the patient’s medical insurance company (or its employees or agents) as may be necessary to process and complete the patient’s medical claim. I understand that I am financially responsible for all charges for services rendered which may include services not covered by the patient’s insurance companies. I agree that all amounts are due upon request and are payable to RGW. I further understand that should my account balance become delinquent and sent to a third-party collector, I agree to pay an additional 30% of the balance or $50, whichever is greater. I also understand that a returned check fee of $35 will be assessed if the check is returned by my bank. The duration of this authorization is indefinite and continues until revoked in writing. I understand that by not signing this release of information, I am responsible for payment of services in full before services are rendered.

Yes, I want The Retina Group of Washington, PLLC (“RGW”) dba The Retina Care Center, an Affiliate of PRISM Vision Group, to communicate my information with me through a secure system that is designed to keep my information safe.

The Notice of Privacy Practices describes how Protected Health Information about you may be used and disclosed and how you can get access to this information. Please review carefully.

The Retina Group of Washington, PLLC (“RGW”) dba The Retina Care Center, an Affiliate of PRISM Vision Group, is required by law to protect the privacy of health information that may reveal your identity, and to provide you with a copy of this notice, which describes the health information privacy practices of our practice, its medical staff, and affiliated health care providers that jointly perform payment activities and business operations with our Practice. “Protected Health Information” is information about you, including demographic information, that may identify you as well as genetic information, and information that relates to your past, present or future physical or mental health or condition and related health care services.

Download our Notice of Privacy Practices

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