Patient Responsibility

COPAYS ARE DUE AT THE TIME OF SERVICE
RESPONSIBLE FOR ANY DEDUCTIBLES OR DENIED CLAIMS BY YOUR INSURANCE
VERIFY IF YOU NEED A REFERRAL FOR YOUR VISIT WITH INSURANCE OR PRIMARY DOCTOR
INFORM US OF ANY CHANGES IN ADDRESS, PHONE NUMBER AND/OR INSURANCE
NO REFUND ON ORDERS OF ANY MATERIALS PLACED AFTER 24 HRS.
THE OFFICE IS NOT RESPONSIBLE FOR ANY ORDERS NOT PICKED UP AFTER 1 MONTH.
PATIENT WILL LOSE BOTH DEPOSIT AND ORDER AFTER 1 MONTH IF NOT PICKED UP
PATIENT WILL BE RESPONSIBLE FOR ANY RE-EXAMINATION FEE AFTER 3 MONTHS OF PICKING UP GLASSES OR CONTACT LENSES

Signature

Office Use Only

I attempted to obtain the patient’s signature in acknowledgment on this Notice of Privacy Practice Acknowledgement, but was unable to do so as documented below:

Patient Responsibility

COPAYS ARE DUE AT THE TIME OF SERVICE

RESPONSIBLE FOR ANY DEDUCTIBLES OR DENIED CLAIMS BY YOUR INSURANCE

VERIFY IF YOU NEED A REFERRAL FOR YOUR VISIT WITH INSURANCE OR PRIMARY DOCTOR

INFORM US OF ANY CHANGES IN ADDRESS, PHONE NUMBER AND/OR INSURANCE

NO REFUND ON ORDERS OF ANY MATERIALS PLACED AFTER 24 HRS.

THE OFFICE IS NOT RESPONSIBLE FOR ANY ORDERS NOT PICKED UP AFTER 1 MONTH.

PATIENT WILL LOSE BOTH DEPOSIT AND ORDER AFTER 1 MONTH IF NOT PICKED UP

PATIENT WILL BE RESPONSIBLE FOR ANY RE-EXAMINATION FEE AFTER 3 MONTHS OF PICKING UP GLASSES OR CONTACT LENSES

Signature

Office Use Only