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. I understand that I am responsible for this additional charge. Additional testing that may be necessary to diagnosis and treat your medical condition may not be covered by your insurance.

I understand that any eye exam that involves dilation of the pupil will temporarily blur my vision for several hours.

Payment is due at time of service unless other arrangements are made with the Billing Department. Payment may be made by cash, check, debit card or credit card.