Transcription of PATIENT FINANCIAL RESPONSIBILITY, ASSIGNMENT OF …
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PATIENT FINANCIAL RESPONSIBILITY, ASSIGNMENT OF …
PATIENT FINANCIAL RESPONSIBILITY, ASSIGNMENT OF BENEFITS, AND NOTICE OF PRIVACY PRACTICE FORM Our goal is to provide you with the best eye health care and positive experience. In order to establish and maintain a pleasant and professional working relationship with you, please take a moment to review the following: 1. FINANCIAL RESPONSIBILTY: Payment is expected at time services are rendered. This includes all copays, coinsurance, deductibles and remaining balance after your insurance is billed. In the event a health or vision plan determines a service to be not covered , you will be responsible for the complete charge.
PATIENT FINANCIAL RESPONSIBILITY, ASSIGNMENT OF BENEFITS, AND NOTICE OF PRIVACY PRACTICE FORM Our goal is to provide you with the best eye health care and positive experience.
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