I understand that Seven Bridges Eye Care may use and disclose necessary personal information (for example, my name, address, subscriber identification number, eye exam information and/or type of products provided) to another party to permit this office to perform it's administrative duties, provide me with eye care services and products, process my vision benefit claims and communicate with me regarding vision care services provided by this office( for example, mailings of exam reminders or information about services/ products provided by this office).

I can be assured that Seven Bridges Eye Care does not sell my personal health information of any kind for any third party's own use. I authorize this office to submit my vision benefit claims to my plan sponsor or health plan to receive reimbursement directly for the vision services and products that I have received.