Financial Policy

Financial Policy

  • I authorize Live Oak Vision, PLLC to use this authorization in place of my physical signature on submissions to my insurance carrier
  • I understand that depending on the nature of the visit, ultimate diagnosis and types of services performed, my medical insurance &/or my routine vision coverage may be filed. Routine vision coverage from a vision plan does not cover exams where medical services are rendered and the appropriate medical insurance will be billed.
  • I understand that insurance deductibles, co-pays, or co-insurance will be collected by Live Oak Vision, PLLC at the time the services are rendered. I understand that if payment for provided services &/or products is denied by my third-party insurance, I am ultimately responsible for these provided services &/or products.
  • Date Format: MM slash DD slash YYYY
  • Acknowledgement of Review of Notice of Privacy Practices

  • I have read and understand the Notice of Privacy Practices of Live Oak Vision, PLLC which explains how my medical information may be used or disclosed. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time to obtain a current copy.
  • Date Format: MM slash DD slash YYYY
  • For Previous Patients of Dr. Jacobs: Authorization For Transfer of Protected Medical Information:
  • The undersigned, whose protected medical information has previously been compiled and maintained by Visual Endeavors, PLLC and Paul C. Jacobs, O.D. hereby provides the authorization and agreement as follows:
  • 1. The protected medical information of the undersigned may be disclosed by Visual Endeavors, PLLC and Paul C. Jacobs, O.D. to Live Oak Vision, PLLC and Karen Summers, O.D.
  • 2. The undersigned consents to the transfer of the ownership and maintenance responsibility relating to the protected medical information of the undersigned by Visual Endeavors, PLLC to Live Oak Vision, PLLC and acknowledges that all future requests relating to the protected medical information of the undersigned shall be submitted to Live Oak Vision, PLLC.
  • 3. The undersigned hereby releases Visual Endeavors, PLLC and Paul C. Jacobs, O.D. from any maintenance obligation relating to the protected medical information of the undersigned, and releases both Visual Endeavors, PLLC and Live Oak Vision, PLLC for its action in reliance upon the authorization granted herein.
  • Date Format: MM slash DD slash YYYY