Date: Patient Name: Date of Birth: Insurance Name:
Your visit for today will be billed through your medical insurance.
The visit today will be charged to your insurance carrier. You have had previous Lasik surgery and the evaluation is no longer free. Charges today will be billed to your insurance carrier. You will be responsible for your copay, deductibles and coinsurance.
During your visit today, which was originally scheduled for a free Lasik Evaluation, we have identified a medical problem which should be evaluated. The office visit and testing will be billed to your insurance carrier, you are still responsible for your copay, deductibles and coinsurance.
The visit today will be charged to your insurance carrier, this is not a free evaluation. Yaldo Eye Center feels that it is important that we monitor your medical condition. Charges today will be billed to your insurance carrier. You will be responsible for your copay, deductibles and coinsurance.
The visit today will be charged to your insurance carrier. You have had previous surgery with us but you are out of your post-op period. You will be responsible for your copay, deductibles and coinsurance.
By signing below, I am confirming that I have been properly notified that today’s visit will be billed to my medical and/or vision insurance. I understand that my insurance carrier may or may not cover all of the testing/visit done today, this may result in a patient balance. Therefore, I agree to accept full responsibility for payment for today’s visit. I understand that it is my responsibility to notify Yaldo Eye Center of any changes in my insurance.
Patient Signature:
