Patient Signatures
Please read carefully and sign your acceptance by entering your First and Last Name in
the boxes below.
View Notice Of Privacy
Practices
ACKNOWLEDGEMENT OF PATIENT PRIVACY
I acknowledge that Ridder Optometry will use and disclose my health information for
purposes of treating me,
obtaining payment for services rendered to me, and conducting health care operations. I
also acknowledge
that I can obtain a copy of Ridder Optometry's Notice of Privacy Practices at our
website, www.ridderoptometry.com, or at our
reception
area by my request.
COMMUNICATION AND COLLECTION POLICY
Payment is due on the day that services are received. Prompt pay discount may be removed if payment is received after the day of service. I hereby agree and consent to being contacted by telephone on any number belonging to me, including my cellular/wireless telephone number or
any number forwarded from or transferred to such number, and I agree that such methods of contact may include the use of SSM/MMS (text)
messages, artificial and/or pre-recorded voices, artificial intelligence, and/or an automated dialing device, some or all of which may result in data
charges. I also understand and agree that such contact(s) may be initiated by Ridder Optometry and/or by any third-party engaged by
Ridder Optometry--including but not limited to third-party debt collectors, and that the purpose(s) of such contact may include
things such as appointment reminders, misc. communications, and attempts to service and/or collect any amounts owed. I also consent to receiving
email communications from the same entities and for the same purposes at any e-mail address belonging to me, or at which I receive e-mails.
I understand and agree that if payment in full is not made as required or any action is needed to otherwise enforce this agreement, then in addition
to all other amounts that may be due or remedy that may be sought, I will be required to pay a collection fee of up to 40% of the principal amount
(as allowed by §12-1-11 of the Utah Code Annotated). I further agree to pay all other costs of collection and/or enforcement including but not
limited to court costs, reasonable attorney fees, and interest (both pre-and post-judgment). Any interest due hereunder shall be calculated at 18%
per annum and may compound as frequently as daily.
AUTHORIZATION TO BILL INSURANCE
I authorize Ridder Optometry doctors, Stephen Ridder O.D. and Jessica Lin Ridder O.D., to
bill my insurance
for all
services provided to me at any office visit. I also authorize my insurance company to
pay the doctors
directly for all services rendered.