Online Patient Forms
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Employed
Fulltime Student
Parttime Student
If yes, please provide the billing address information below
Not Primary On Account: Not Primary
Dry Eye Disease
In order to control the cost of billing, we ask that the patients portion Is paid at the time services are rendered unless other arrangements are made in advance. We would rather control billing costs than be forced to raise our fees. All professional services and materials are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts past due are subject to collection. I agree to pay any legal and collection agency fees and interest in the event of delinquency. There will be a service charge on all returned checks. Payment from my insurance is to be paid directly to Priority Eye Care. I understand that if my insurance denies payment, I will be responsible for the amount billed. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance company and that final determination can only be made when the claim is processed.