• SHEA FERREE CARNEY, O.D.
    MARIE HUMPHREY. O.D.

    WELCOME TO OUR OFFICE!

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  • PERSON RESPONSIBLE FOR THIS ACCOUNT

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  • AUTHORIZATION/RESPONSIBILITY AGREEMENT

    Payment is expected at the time professional services are rendered. A 50% deposit is required before materials are ordered; balance is due upon delivery of materials.

    I have requested Marston Optometry to bill my insurance company for covered services on my behalf. I clearly understand that it is still my responsibility to make sure that the bill is paid in a reasonable time. If for any reason any portion of my bill is not paid by my insurance, I further agree to make arrangements for prompt payment of the bill.

    I hereby authorize any insurance company to pay the proceeds of any of my benefits due me directly to Marston Optometry a copy of this can be considered as an original for insurance purposes.

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  • In order to process a claim for benefits, I authorize Marston Optometry or my insurance company to release all information with respect to myself or any of my dependents which may have a bearing on the benefits payable under any plan providing benefits or services. I certify that the information provided by me in support of claims is true and correct. A photocopy of this authorization shall be considered as effective and valid as the original.

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