Payment for Services, Financial Responsibility, and Authorization Statement
Payment for all services and products is the responsibility of the patient.
I agree to pay all copays, deductibles, co-insurances, and non-covered services as determined by my insurance company.
I agree to pay an additional collection fee for all accounts not paid in the time stated on the final monthly statement.
I authorize the release of medical information concerning my illness and treatment to my insurance company.
I authorize the release of my personal medical information to any doctor whom I may be referred to.
I understand verification of eligibility is not a guarantee of payment as stated by my insurance company.
I authorize payment of my insurance benefits to Blinc Eye Care.