Health and accident insurance policies are a contractual arrangement between an insurance carrier and the insured. It is the responsibility of the insured to verify eligibility for health care benefits. Possession of a medical insurance member ID card is NOT a guarantee of coverage. As a courtesy to you, we will submit your medical bills to your insurance carrier.

1.Insurance: I request that payment of authorized benefits be made on my behalf to EyeJoy for services furnished to me by EyeJoy. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents any information needed to determine these benefits or the release of medical information necessary to pay the claim. EyeJoy accepts the charge determination of the carrier as the full charge, and I am responsible for the deductible, coinsurance, co-pays, and non-covered services. Coinsurance and deductibles are based upon the charge determination of the carrier and are due at the time of service. Any benefits of any type under any policy of insurance insuring the patient or any other party liable to the patient is hereby assigned to EyeJoy. As a courtesy, EyeJoy will file your insurance for you, however, by signing below you are stating that you understand that you as the patient are ultimately responsible for payment for services rendered.

2. Release of Information: EyeJoy may disclose all or any part of my medical record and/or financial ledger to any person or corporation which is or may be liable or under contract with EyeJoy for reimbursement for services rendered .

3. Non-Covered Services: I understand that EyeJoy contracts with health insurance plans. Accordingly, the undersigned accepts full financial responsibility for all items and services which are determined by the health care insurance plan as non-covered services.

4. Financial Agreement: I agree that in return for the services provided to me by EyeJoy, I will pay my account at the time service is rendered or will make financial arrangements satisfactory to EyeJoy for payment. If an account is sent to collections, I agree to pay collection expenses. I understand and agree that if my account is delinquent, I may be charged a service fee. It is understood that the undersigned and/or the patient are primarily responsible for the payment of the bill. The parent/legal guardian bringing the child to our facility will be responsible for required payments at the time of service.

This assignment will remain in effect until revoked by me in writing. A photocopy or an electronic version of this assignment is to be considered as valid as an original.