Due to the ongoing development of the COVID-19 pandemic, all Gailey Eye Clinic locations, including Bloomington Eye Institute and Gailey Eye Surgery-Decatur will remain closed through April 30th. Patients who have an appointment scheduled during our closure dates will be called to re-schedule for a future appointment date. For eye-related emergencies, please call your local Gailey Eye Clinic and you will be instructed on how to proceed. If you have any other questions or concerns, the best way to contact us during this time is via email at email@example.com. We will be monitoring email inquiries daily.
If you would prefer to download a PDF version of this form and return to the office, please click here.
My electronic consent below indicates that I have been given the chance to review such copy of the Notice of Privacy Practices. My signature means that I agree to allow Gailey Eye Clinic, LTD./Bloomington Eye Institute, LLC/Gailey Eye Surgery ‐ Decatur to use and disclose my protected health information to carry out treatment, payment, and health care operations, including release of medical information to my insurance/Medicare carrier to determine benefits payable for related services. I understand that I am financially responsible to the clinic for any charges covered by this authorization. Some routine eye‐care costs (i.e. refractions) are generally not covered by insurance/Medicare. I understand that these costs are my responsibility. In the event collection efforts become necessary I agree to pay all reasonable collections costs up to 40% of the amount owed, plus reasonable attorney fees and court costs. I have the right to revoke this consent in writing at any time, except to the extent that Gailey Eye Clinic, LTD./Bloomington Eye Institute, LLC/Gailey Eye Surgery ‐ Decatur has taken action relying on this consent.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our ‘Notice’ at any time by contacting: Gailey Eye Clinic, LTD., 1008 N. Main St., Bloomington, IL 61701 800-325-7706.