EyePromise

My Vision Needs

My Health​​​​​​​

New Patients Only

My Doctors​​​​​​​

Financial Responsibility & Acknowledgement of Privacy Practices​​​​​​​

By signing below, I acknowledge that a copy of Claremore Eye Associates Notice of Privacy Practices has been made available to me. I hereby authorize any necessary medical treatment by the optometrists in the practice of Claremore Eye Associates, and agree to be financially responsible for my bill for materials and/or services rendered. I authorize this oce to release any information necessary to expedite insurance claims. I further authorize Claremore Eye Associates to release or obtain any required medical information from my attending physicians or any medical facility as necessary for my care and to decide which insurance plan should be billed for my services. I also authorize my insurance provider to make payments on my behalf to Claremore Eye Associates. Payments for services rendered are non-refundable. Your medical records will be electronically archived indefinitely, and all discarded documents are shredded to protect personal information. Our oce may use standard email to communicate with you for the purpose of sending payment receipts or copies of your glasses/contact prescriptions.