Eyes on Evesham, LLC
Your MEDICAL INSURANCE is billed for MEDICAL conditions (diabetes, red eyes) and your VISION plan is billed for VISION related services (glasses). These visits might also have to be billed over SEPERATE visits. These are the guidelines dictated by the insurance companies.
All professional services are non refundable.
I UNDERSTAND I AM RESPONSIBLE FOR KNOWING THE BENEFITS MY INSURANCE PROVIDES.
BY SIGNING BELOW, I HEREBY AUTHORIZE EYES ON EVESHAM, LLC, TO DISCLOSE ANY NECESSARY INFORMATION; TO ANY PHYSICIANS FOR THE PURPOSE OF PROVIDING CONTINUING PROFESSIONAL CARE AND TO ANY INSURANCE COMPANY/THIRD PARTY PAYER, FOR THE PURPOSE OF OBTAINING PAYMENT TO EYES ON EVESHAM, LLC FOR SERVICES PROVIDED.
I HEREBY AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO EYES ON EVESHAM, LLC.
IF PAYMENT IS DENIED BY THE INSURANCE COMPANY I AGREE TO BE PERSONALLY AND FULLY RESONSIBLE FOR PAYMENT.
BY SIGNING BELOW; I ACKNOWLEDGE AND ACCEPT THE TERMS AND CONDITIONS SET FORTH ON THIS FORM