I, the undersigned, authorize payment from my insurance company to be made to Fowle Eyecare Associates PLC, for covered services. I understand that I am responsible for obtaining any referrals necessary before my appointment or I must pay in full for that visit. Regardless of my insurance status, I am ultimately responsible for the balance on my account.
Should timely payments of this account not be made, I authorize Fowle Eyecare Associates, PLC, to retain the services of an attorney and/or collection agency to assist with the collection of any outstanding balance. Any expenses incurred by such action shall become my responsibility.
I certify that the information I have provided with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information, to my insurance company in order to determine insurance benefits to which I may be entitled.
This authorization may be revoked by myself at any time in writing.