PAYMENT AT TIME OF SERVICE
Payment is expected at the time the service or procedure is performed.

For Contact Lenses:
At least half the total cost is due on the day they are ordered and the balance must be paid the day you pick them up.

For Insurance Assignment Situations:
When we accept assignment of fees set by your insurance carrier, you will be responsible for any deductible or co-insurance payments that may apply

INSURANCE CLAIM FILING

Courtesy Filing Service:
We will file your Medicare and Blue Cross Blue Shield of NC claims for all services and procedures we provide. If your insurance company pays you directly for a service given by us please remember to bring us this check as soon as possible, unless you have already paid for the service.

Our Financial Relationship:
You should understand that our account is directly with you, not your insurance company. You are responsible for your bill with us.

Questions?:
If you have any questions about your financial responsibilities or Watson Eye, PA. payment policies, please do not hesitate to talk with us about your concerns.

SIGNATURE ON FILE

I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration or its intermediaries or Carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to he used in place of the original, and request payment of medical insurance benefits either to myself or to the party who accepts assignment. Regulations pertaining to Medicare assignment of benefits apply

COMPLIANCE STATEMENT
I have read and I understand the above financial policies and I agree to abide by them.

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Patient or Responsible Party / Date