I, the undersigned, certify that I or my department have insurance coverage with the above Insurance Company and assign directly to Moon Valley Eyecare all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance, final amount based upon EOB. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

In the event that I/we have failed to pay for services provided by this office, and the account is placed for collection, I/we understand and agree that an additional amount equal to 40% of the balance owed at the time the account is placed for collection, will be added to the current balance owed. I/we agree to pay interest at the rate (10%) ten percent per annum until the amount owed is paid in full. I/we further agree to pay all attorneys fee and court cost, necessary to collect this balance. Non-sufficient checks will be charged an additional $30.00 bank fee.

Our doctor strives to see patients in a timely manner. We respect your time and ask you to respect our time and other patients’ needs by keeping your appointment. Each appointment time slot is important and cannot be recovered if a patient chooses not to keep their appointment. We collect fees to ensure that our doctor can continue to see patients. Please keep in mind that each skipped or missed appointment is not just time lost, but also time when other patients cannot be seen. Each missed appointment will be flagged and you will receive a notice that you have missed your appointment. In addition, your account will be assessed a $30 missed appointment fee. Please note that the fee will not be billed to your insurance. I understand that failure to give 24-hour notice of cancellation of an appointment or not showing up for an appointment can result in a charge of $30. This charge is non-covered by your insurance company and is your responsibility.

On April 14, 2003 a new Federal Law HIPPAA, went into effect to protect your personal health information (PHI). If you need to authorize someone else to have access to your records in our office please list them and their relationship to you below. Please note, that under this new law we cannot release information to a spouse or parent if the minor is 18 or older, regardless of who is responsible for the charges.

I hereby authorize Moon Valley Eyecare to release my PHI to the listed individuals above until I submit a written request to withdraw them from having such access.