Patient History/Authorization for Payment/Contact Lens Evaluation and Fitting Fees Form

This form contains confidential information and is delivered to your doctor through a secure Internet connection.

• Eye Care Center participates with many medical insurances and vision plans. Evidence of active coverage is required at the time of service (by providing us with insurance card or ID number) or payment will be due on the date of service.
• Payment for all services and products is the responsibility of the patient and due at time of service.
• Your eye care benefit is a contract between you, your employer and the insurance company. We are not a party to that contract and this office will file your claims as a courtesy to you.
• Not all services are a covered benefit in all contracts. It is your responsibility to know your benefits.
• We accept cash, checks and all major credit cards, including FSA/HSA benefit cards.

• I agree to pay all copays, deductibles, co-insurances, and non-covered services as determined by my insurance company.
• I agree to pay balances due in a timely manner or incur additional collection fee for past due accounts.
• I authorize the release of medical information concerning my illness and treatment to my insurance company.
• I authorize the release of my personal medical information to any doctor whom I may be referred to.
• I understand verification of eligibility is not a guarantee of payment as stated by my insurance company.

• I authorize payment of my insurance benefits to Eye Care Center, Dr. Amanda Hale, O.D.