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Payment Policy: By making an appointment at Mountain View Vision, you are agreeing to abide by all billing policies of our practice. Payment is required at the time services are rendered or materials are ordered. Quotes of insurance coverage are based on information from the insurance company and are not guaranteed. Although we will gladly bill insurance for you, the patient remains responsible for their charges even after the insurance has been billed. If payment has not been received from insurance after 60 days, the patient will be expected to pay Mountain View Vision directly.
Financial Responsibility: I understand that I am personally responsible for payment of my account even if I have insurance. If it becomes necessary to use a collection agency for any amount owed on this or subsequent visits, the undersigned agrees to pay all costs and expenses including reasonable attorney’s fees. Accounts assigned to collections will be charged a $50 collections fee.
Cancellation Fee: A cancellation charge of $50 may be billed to you personally if you do not provide at least 24 hours’ notice of a cancellation or change in your in your appointment date or time.
No Show Fee: A no show charge of $50 may be billed to you personally if you do not show for your scheduled appointment.
Release of Information: I hereby authorize release of my information to my insurance company or to any health care professional or education professional when necessary for my health care billing. (This allows us to bill your insurance.)
These policies will be enforced for both new patients and established patients. Our staff will be happy to answer any further question regarding these policies.
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