I understand that you will bill my insurance as a courtesy to me. However, I also understand that I am ultimately
responsible for the total amount due, should my insurance company decline to pay or if I do not have insurance. I
understand that payment of at least half of my portion of the total bill (including any co-pays) is expected at the time
services are rendered and before my glasses or my contacts will be ordered. I authorize my insurance company to make
payment directly to the provider. If my insurance company pays me instead of the provider, when the provider should
have received the payment, I agree to inform the provider and pay the amount owed in full. I am aware that there is a
$25.00 returned check fee policy in effect in this office. I understand that if my account is delinquent at 120 days past
service date, it may be turned over to collections. Should my account have to be turned over to collections, I agree to be
responsible for any extra fees that this office might incur due to such a situation, including a $25.00 processing fee and
any and all municipal charges. All Family Vision Care asks that you notify our office at least 24 hours in advance
when you are unable to keep your scheduled appointment. A “no show” will result in a $25 charge to be added to
your account. My signature on this form is acceptance of these terms and may also be used as the signature on file for
insurance purposes. If I have any questions regarding any of this information I am free to inquire before my exam and
before I place an order. Signature is required before an exam takes place and before an order is placed.
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