HIIPA Acknowledgement

I acknowledge that I have been given the opportunity to review

Acuity NYC’s Notice of Privacy Practices.

Statement of Financial Responsibility

 

I understand that payment is due at time service is rendered.

Acuity NYC is considered an “Out of Network” provider by most insurance companies and does not accept assignment on claims.

A fully coded Insurance form can be provided to you at your request for you to submit your claim.

I understand that most health care insurers, including MEDICARE, DO NOT cover refractions or contact lens fittings, and will reject these charges.

In the event that my insurer issues reimbursement to Acuity NYC, the payment will be returned to me.