I authorize Craig A. Fidler, O.D., P.A. / Fidler EyeCare (provider) to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eyecare to third-party payers and/or health practitioners.

I authorize and request my insurance company to pay directly to the provider insurance benefits otherwise payable to me. I understand that my eyecare insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
I acknowledge that I have viewed and had the opportunity to save a copy of Craig A. Fidler OD PA/Fidler EyeCare’s Notice of Privacy Practices at www.FidlerEyeCare.net