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Payment and Privacy Agreement

Payment and Privacy Agreement

Please fill out and sign this form annually.  This helps protect your information and allows us to share critical information with assigned family or other individuals.  Let us know if you have any questions.

I, the undersigned, certify that I or my dependent(s) have insurance coverage as I have provided and assign directly to Dr. Roger Pickering all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid or covered by insurance. I also understand that copays are due at time of service. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of the signature on all insurance submissions. I understand that I am liable for all applicable collection fees, if I do not pay my fees, up to the maximum allowed by law. I understand that optical purchases as well as professional fees are customized and not subject to refund. I authorize Dr. Pickering to share the results of my examination with other professionals, if necessary, to ensure my best health care. 

Release of Information & Materials


I authorize the release of information including the diagnosis, prescription, records, examination rendered, and claims information by phone, in person, or in writing to the following individuals. The release of information will remain in effect until termination by me in writing. 

I authorize that contact lenses, glasses or other goods purchased at Lehi VIsion Care may be picked up by the following individuals:

Thanks for submitting!

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