[5557] Northern Valley Eye Care

Dr. Alan Ross
Optometrist
Thank you for selecting our office. We look forward to working with you in maintaining your vision.

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We appreciate you choosing our office! Whom may we thank for referring you to our office?

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Insurance Information

Patients must provide insurance card prior to exam

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Is your billing informaion the same as the address above?

Yes

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SIGNATURE ON FILE

I REQUEST THAT PAYMENT OF AUUTHORIZED MEDICARE AND ANY OTHER INSURANCE BENEFITES BE MADE ON MY BEHALF TO DR. ALAN ROSS O.D. FOR MY SERVICE FURNISHED BY MY PHYSICAN. I AUTHORIZED ANY HOLDER OF MEDICAL INFORMATION ABOUT ME TO BE RELEASED TO THE HEALTH CARE FINANCING ADMINISTRATION AND ITS AGENTS ANY INFORMATION NEEDED TO DETERMINE THESE BENEFITS FOR PAYABLE SERVICE.

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PAYMENT POLICY

ALL CO-PAYS AND PAYMENTS ARE DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, AND ALL MAJOR CREDIT CARDS. IF YOU HAVE INSURANCE, WE WILL BE HAPPY TO BILL THE ESTIMATED PORTION YOUR INSURANCE PLAN COVERS; THE REMAINING BALANCE IS DUUE AT THE TIME OF SERVICE. YOUR CARRIER IS YOUR BEST SOURCE OF INFORMATION REGARDING BENEFITS AND ELIGIBILITY. IF THE INSURANCE DOES NOT PAY, PATIENT IS RESPONSIBLE FOR THE OUTSTANDING PAYMENTS.

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