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Patient Agreement

I realize that I am financially responsible for all services rendered to me by Washington Eye Doctors (the Practice).

All professional fees are due when service is rendered.

All eyewear and contact lenses must be paid for in full when ordered.

There is a $15.00 fee for all returned checks.

A collection fee equal to 35% of the balance due will be added to all accounts referred for collection services.

The practice reserves the right to charge for canceled or missed appointments with less than 24 hours notice.

INSURANCE AUTHORIZATION

For those insurances for which the Practice accepts assignment, I realize that I am personally responsible for all co-payments, deductibles and non-covered services, as dictated by my insurance coverage.

I hereby authorize Washington Eye Doctors to apply for benefits for covered services rendered by the Practice and request that the payments from Medicare Part B, Vision Service Plan and/ or my insurance carrier be paid directly to the Practice.

I certify that the information that I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim to my insurance carrier(s) (or in the case of Medicare Part B benefits, to the Social Security Administration and Health Care Financing Administration).  I permit a copy of this authorization to be used in place of the original.