Financial and Insurance Policy Consent and Disclosure

I have read, understood, and agree to authorize "Dr. Kurtbay Optometry" to submit and sign insurance claims on my behalf. I also authorize the release of any information pertinent to my insurance company or their agents. I understand that this authorization is a direct assignment of my rights and benefits under my policy and that the payments will be paid directly to "Dr. Kurtbay Optometry." I agree to be responsible for all fees not covered by my vision insurance or should my insurance company deny payment to Dr. Kurtbay Optometry.

Consent for Electronic Delivery of Prescriptions

I acknowledge that my prescription for glasses and/or contact lenses will be sent to me via email.