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The Salem Eyecare Center, Incadmin2017-07-06T01:14:30+00:00

The Salem Eyecare Center, Inc

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  • Patient's Employment (if applicable)

  • Insurance Information

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  • Family Members Interested In Becoming Patients

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  • Co-Payments and fees not covered by your insurance are due upon date of service. A DOWN PAYMENT of 50% is required on materials to start your order. The balance will be due upon pick up of your eyewear. THERE ARE NO CASH REFUNDS ON MATERIALS.
  • If a prior authorization is required by your insurance, it is the patient's responsibility to contact their primary care provider.
  • FINANCIAL RESPONSIBILITY & ASSIGNMENT OF BENEFITS TO SALEM EYECARE CENTER:

    I assign to Salem Eyecare Center all medical and vision benefits to which I am entitled. I understand that I am responsible for all charges for professional services rendered. (Except for participating provider agreements between this corporation and your insurance company). I am specifically responsible for certain co-payments and deductibles. I understand that refractive services and other forms of medical care may not be reimbursed by my health care plan and that I will be responsible for these services. A copy of this agreement is also valid. The agreement shall remain in effect until revoked by me in writing. I understand I will be subject to a re-filing fee for supplying false insurance information at date of service.
  • FULL AUTHORIZATION FOR INFORMATION TRANSFER:

    I authorize this office to furnish information (including sensitive medical information) to insurance carriers, healthcare administrators, healthcare providers, and other agencies concerning my medical condition, personal data, and insurance/billing information.
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