I understand that it is the patient’s responsibility to supply SUSQUEHANNA EYE ASSOCIATES with any current insurance information and/or any referral authorization forms that may be necessary for my insurance. I am aware that if I have a routine diagnosis my insurance may not cover this appointment.
I authorize SUSQUEHANNA EYE ASSOCIATES to receive payments for medical services rendered to my dependents or myself. These authorizations will remain in file for all future treatments.
I AM AWARE THAT I AM RESPONSIBLE FOR ANY UNPAID BALANCES.
I understand that Medicare and most insurance companies do not cover standard care or eye refractions (eyeglass prescriptions) and that I will be fully responsible for these charges. I understand that insurance companies require beneficiaries to pay deductibles, company insurance, co-payments, and any non-covered services at the time of services are rendered.
Most insurance companies do not cover the contact lens fitting or contact lens modification. The contact lens modification is a yearly charge that is separate from the eye exam charge. From the eye exam charge. I understand that I am responsible for this additional charge.
I understand that a comprehensive eye exam involves dilation of the pupil, which may temporarily blur my vision for several hours.
IT IS CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE. WE GLADLY ACCEPT CASH, CHECK, MC, VISA, AMERICAN EXPRESS AND DISCOVER.