Select all that Apply

I, the undersigned may have insurance coverage and/or vision plan coverage with an insurance carrier(s)/ or surgical benefits, if any, otherwise payable to me for services rendered. I hereby request that Bhend Family Eye Care, PLLC dba You and Eye to file any claim(s) for medical and or/ preventative care benefits with my medical carrier prior to filing a claim(s) with any vision plan carrier or free standing vision plan unless I indicate otherwise at time of service. I hereby authorize the release of all information necessary to secure the payment of benefits. As part of Dr. Bhend's annual recall program, I authorize Bhend Family Eye Care, PLLC dba You and Eye to utilize my name, mailing address, phone number, e-mail address and next appointment date and time to Bhend Family Eye Care, PLLC dba You and Eye for the purpose of providing annual reminder postcards, coupons and product information. I understand that I am financially responsible for all charges whether or not paid by insurance or vision plans; Co-pay, Co-insurance, and Deductibles are due at the time of service; Contact lens fitting fees, which are not generally covered by insurance nor a part of a routine eye exam, are due at the time of service; Bhend Family Eye Care, PLLC dba You and Eye charges $30.00 for any check returned from your bank; returned check fee(s) will be added to my unpaid balance and must be paid by credit card or in cash. Contact lens fitting fees are good for 90 days from date of original contact lens fitting; any contact lens fitting not completed within 90 days may incur additional fees.

I acknowledge that I have either been given access to and reviews or received a copy of the Office's Notice of Privacy Practices, ("Notice") which describes how my health information is used and shared. I understand that the Office has the right to change this Notice at any time. I may obtain a current copy by contacting the Office Privacy Officer.