Welcome to The South Eastern Eye Center! Please review the information listed below and complete it in its entirety. If information does not pertain to you simply put NA or mark it with NO. Keep in mind that our goal is to see you as efficiently as possible so all appointment concerns will be managed as listed below. Our facility reserves the right to treat medical eye problems as determined by the information provided below. If you have a medical issue but do not provide your medical insurance you will be required to pay for those additional services prior to leaving the office today or you may be asked to return with a referral based on your insurance structure to cover those service needs.
Please list if YOU or ANY FAMILY MEMBER has any of the following conditions: DO NOT LEAVE BLANK MARK Yes or No
Please Note: Insurance may cover only part of your charges, or may be payable directly to you. Please give any forms or insurance cards to the receptionist in order to process your claim. If your insurance company does not pay as expected, you are ultimately responsible for all charges. Filing your insurance is a courtesy service we provide for our patients.
Your signature below shows your understanding and acknowledgement of our office’s HIPAA documentation. * This signature also authorizes the release and payment of any medical or other information to process claims filed pertaining to services rendered at this office. I understand and agree that professional services are NONREFUNDABLE.
Method of Payment today: Cash Visa MasterCard Star Card Care Credit Amex
A service charge of 1 ½ % per month, 18% APR may be added to overdue accounts. You will also be liable for legal and collection costs.
*Your signature above is acknowledgement of the fact that you have been given the rights to review a copy of our office’s HIPAA document and non-payment of outstanding balances will be transferred to you and or the guarantor or your command if necessary.