PATIENT FINANCIAL RESPONIBILITY FORM
We ask that you read and sign below to acknowledge your understanding of our patient financial policies.
Patient Financial Responsibilities:
- The patient (or guardian, if a minor) is ultimately responsible for the payment for treatment and care. Authorization from your insurance is Not a guarantee of payment.
- We will bill your insurance for you. However, the patient is required to provide the most correct and updated information
- Patients are 100% responsible for payments of copays, deductibles, all other services, procedures or treatments not covered and/or excluded by your insurance coverage. This includes refractions, all overages on materials, options, and quantities not covered by insurance.
- Copays are due at time of service.
- Coinsurance, deductibles and non-covered items are due 30 days from receipt of billing.
- Patients may incur, and are responsible for payments of additional charges, if applicable.
These charges may include:
- Returned check fee: $25.00
By my signature below, I hereby authorize assignment of financial benefits to Enhanced Eye Care and any associated healthcare By my entities for services rendered as allowable understand standard third party contracts.
I understand that I am financially responsible for charges not covered by this assignment.