I authorize my insurance company to pay the doctor or medical group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions. I authorize the doctor to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
24 hours notice MUST be given if you cannot keep an appointment for any eye exam. If notice is not given a $50.00 fee will be assessed.