Notes: Most Insurance policies pay only a portion of your total charges. If you have questions about your coverage, please contact your insurance representative. We do not guarantee the accuracy of benefit information given to us by insurance companies.
Please understand that financial responsibility for your account is yours, not your insurance company's
I authorize the release of any medical or other information necessary to process insurance claims.
I authorize payment of medical or vision benefits to the physicians or supplier for services rendered.
I understand that I am responsible for any balance my insurance does not pay.
All above is correct to the best of my knowledge.
I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY.
If you are signing as a personal representative of the patient, please indicate your relationship.
Starting November 1, 2018
We will no longer be refunding money less than $50.00, any over payment less than $50.00 will be applied to the patient’s account. If you desire to have a refund mailed to you, please call the office.
© 2020 Coulter Drive Optical. All Rights Reserved. | Designed by PECAA