Please indicate if you or any blood relatives have been diagnosed with any of the following medical conditions:
I authorize Drs. Steve and Stacey Beck to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such eye care to third party payers for the purpose of payment, and/or health practitioners until otherwise requested in writing. I assign all insurance benefits, if any, to Drs. Beck otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Optix Optometry requires payment in full for examination fees and all materials at the time of service or ordering. We accept cash, checks, money orders, Visa, Master Card and Discover. An overdraft fee of $25.00 will be assessed for returned checks. Client(s) will be responsible for any balances owed. If balances are not paid, the client will be responsible for all collection agency fees and attorney fees totaling an additional 25% of the current account balance at the time the account is sent to collections.
All patients who wear or elect to wear contact lenses will be enrolled in the Contact Lens Care Program and will be assessed any applicable professional fees related to contact lens fitting and evaluations.
“I have read the contents of this page and understand by signing my name, I agree to all of the terms and conditions.”