I consent to the use and disclosure by the offices of Diamond Optical Care, any information, (i.e. health information concerning my vision examination and related products) to any party and/or agent, including, but not limited to my employer, health plan or vision benefit claims, and related customer communications regarding health care services provided by the offices of Diamond Optical Care (i.e. mailings of exam reminder/recall cards or explanations of services/products provided by the office).

If I desire to seek third party reimbursement for the services received, I authorize the offices of Diamond Optical Care to submit a vision benefit claim for payment to any third party as identified. I understand that I am responsible for all charges incurred, including any portion not paid by any third party.

I understand that this consent for release of information is voluntary and that I may revoke my consent at any time by notifying the offices of Diamond Optical Care in writing, except for any disclosure already taken in reliance of my consent to release of information. I understand that I may request that the offices of Diamond Optical Care restrict the use and disclosure of my personal information; however, the office is not required to agree to my request.