Consent Form - Greenbush Eye Center printable pdf download

Consent Form - Greenbush Eye Center

CONSENT FORMS

WHO IS RESPONSIBLE FOR PAYMENT?

SELF:____IF SOMEONE ELSE, WHO?________________________________________________

NAME:_____________________________RELATIONSHIP TO YOU:_______________________

ADDRESS:__________________________CITY:____________STATE:______ZIP:_____________

Assignment and Release: I hereby authorize my insurance benefits be paid directly to Greenbush Eye

Center and I acknowledge that I am financially responsible for any unpaid balance. I also authorize

Greenbush Eye Center to release any information required to process said claims.

I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT

THEY ARE COVERED BY INSURANCE. I FURTHER UNDERSTAND IF I HAVE

INSURANCE AND DO NOT INFORM YOU OF IT TODAY, THERE WILL BE A $25

SERVICE FEE TO PROCESS A CLAIM AFTER THE DATE OF SERVICE.

All eyeglass orders are final. Since prescription eyewear is a custom-made product that is

ordered within 24 hours if not on the same day of service, once it is ordered it cannot be canceled

or refunded. It can be exchanged for a different product or an office credit will be issued.

Date:

Patient/Guardian Signature:

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of Greenbush Eye Center's, Notice of Privacy Practices.

Date ___________ Patient name______________________Signature _________________________

In addition to the usual entities, I authorize Greenbush Eye Center to disclose my health information to

the following parties (this authorization shall remain in affect until we receive notice in writing from

you of any changes):

Date:____________ Patient name:__________________ Signature:_______________________

Consent Form - Greenbush Eye Center