Our Pledge

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive at our clinic. We need this record to provide you with quality care and to comply with certain legal reguirements. This notice will tell you about the ways we may use and share medical information about you. This document also describes your rights and certain duties we have regarding the use and disclosure of your medical information.

Our Legal Duty

Use and Disclosure of Your Medical Information

These are the various ways we use and disclose medical information. Each and every use and disclosure can not be listed. But those that are listed are all the ways we are permitted to use and disclose medical information. We will not use or disclose your medical information for any purpose not listed below, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us.


Please check the box next to each statement indicating how you would like us to properly communicate with you regarding your health information.

I, have received the Notices of Privacy Practices of Kevin A. Tanner, O.D., and I have been provided the opportunity to review it. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations.

If signing as a personal representative of the patient, please describe the relationship to the patient:

Digital Retinal Imaging

We are pleased to provide you with the latest technology to aid in detecting and monitoring eye disease, and preserving sight. Dr. Tanner recommends digital retinal imaging for all patients. He uses this technology to document the appearance of the inside of your eyes. It enables him to review and compare your retina over time. Many diseases such as Macular Degeneration, Glaucoma, Hypertension, Diabetes, as well as other health issues can be detected with these images. It can be performed without dilation. There is an additional $19 charge for this procedure because it is not covered by insurance.

Do you want to have Digital Retinal Imaging performed during your examination?

Payment Information

Payment is expected at the time services are rendered. One-half the cost of materials will be due at the time an order is placed. The balance is due at the time materials are dispensed or picked up. Accounts left unpaid will be charged a billing fee each month. After 3 attempts to collect, your account will be turned over to collections with all added fees for which you will be responsible to pay. There is an additional fee of $35 for any account sent to collections.
I, understand that I am responsible for the total amount due or any amount unpaid by my insurance company. Any denial or dispute of payment by my insurance company is my responsibility and not Premier Family Eyecare. If insurance is being billed by Premier Family Eyecare, this electronic signature serves as your "signature on file".

If signing as a personal representative of the patient, please describe the relationship to the patient: