Patient Agreements
At Ocean Park Optometry, we value your privacy and protect your health information. Please review our Notice of Privacy Policy.
By signing below:
- I acknowledge receipt of the Notice of Privacy Policy.
- I have reviewed the Fees.
- I acknowledge full financial responsibility for all charges incurred by me for services and products, regardless of insurance.
- I understand that in order to use my benefits, I must provide all necessary information regarding my insurance prior to my services or purchases.
- I understand that my insurance company does not guarantee any payment, even with prior authorization, and that my insurance company may deny payment when the claim is processed.
- I understand that payment of the portion of the charges not covered by insurance, including deductibles, co-pays, overages, and all prior balances, is due at the time of service.
- I understand that custom orders cannot be cancelled or changed after the order has been placed. There are no refunds on custom orders.
- I authorize insurance payments to be made directly to Ocean Park Optometry.
- I understand that there will be a $75 no show fee for appointments not kept without a minimum 48 hours prior notice. For Neurovisual examinations, a $150 no show fee will apply if a 1 week prior notice is not given.
- I understand that there will be a $35 service charge on all returned checks.
- I understand that delivery times are estimates only and cannot be guaranteed due to factors beyond our control.
- I agree to receive an electronic copy of my prescription, and upon request I can also get a hard copy within my visit given that the prescription has been finalized.
- I understand that any balances unpaid after 90 days will incur finance charges.
- I agree to all reasonable attorney fees and collection costs in the event of default of payment of my charges.
- All of the information I have submitted is correct to the best of my knowledge.
