Financial Policy and Acknowledgement

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Financial Policy and Acknowledgement

Please read our financial policy and sign below. Fields marked * are required.

Patient Information

Financial Policy

Payment is due at the time of service unless prior arrangements have been made. We accept cash, check, Visa, MasterCard, and Discover. Insurance: We will bill your primary insurance as a courtesy. You are responsible for any co-pays, deductibles, or non-covered services at the time of your visit. If we have not received payment from your insurance within 60 days, the balance becomes your responsibility. Vision Insurance: We only accept Blue View Vision. If you have VSP, Eyemed, Davis Vision, or Delta Dental/Vision, you do not have routine coverage at our office. Returned Checks: A $25 fee will be charged for any returned checks. Collections: Accounts more than 90 days past due may be referred to a collection agency. You will be responsible for all collection costs.

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