I hereby authorize Eyes On Norbeck Vision Care to apply for benefits on my behalf for covered services rendered by them. I request payment to be made directly to their office. I understand that I am financially responsible for the charges not covered by my insurance company. I certify that the information I have reported with regards to my insurance coverage is correct and further authorize the release of any information, including medical information, for this or any related claim. I permit a copy of this authorization to be used in place of the original. If in the event my account is turned over to a collection agency, I will be responsible for all collection costs, interest, attorneys’ fees and court costs. Please note: The patient is responsible for full payment of services if information is not made available, not current, information is not accurate, benefits are not available, or patient fails to present insurance information. The patient will also be responsible for submitting themselves to agencies for reimbursement if proper information is not provided to office staff.
Thank you for choosing us for your eye care needs. We are delighted to have you as a patient and appreciate the confidence you have placed in us. If you have any questions about this form, please do not hesitate to ask.