I, the undersigned, authorize payment from my insurance company to be made to Fowle Eyecare Associates PLC, for covered services. I understand that I am responsible for obtaining any referrals necessary before my appointment or I must pay in full for that visit. Regardless of my insurance status, I am ultimately responsible for the balance on my account.
Should timely payments of this account not be made, I authorize Fowle Eyecare Associates, PLC, to retain ofwith and/orthe servicescollection theanattorneycollectiontoassistofoutstandingbalance. agencyany Any expenses incurred by such action shall become my responsibility.
I certify that the information I have provided with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, to my insurance company in order to determine insurance benefits to which I may be entitled.
This authorization may be revoked by myself at any time in writing.
****** A NOTE TO ALL OUR CONTACT LENS WEARERS ******
In most cases, contact lenses are not considered "medically necessary" by insurance companies. Any costs performed to determine or update a contact lens prescription may not be covered by most insurance companies and will be the responsibility of the patient. Please list the person financially responsible for this
** No Show Policy** - out of respect to others who want to schedule with our Doctors, not showing for a scheduled appointment will incur a charge of $50