Financial Responsibility Form

Financial Responsibility Form

I authorize SAMUELSON EYECARE to bill my insurance company for services rendered and/or materials purchased. I understand that only covered services will be billed. All COPAYS are due at the time of exam. If the service is not covered, then that balance is my responsibility and is due when services are rendered. If the insurance company does not pay the claim within 60 days and/or if they only pay a portion of the claim, I understand that I am responsible for paying the remaining balance.

If the outstanding balance is not paid within 90 days, then there will be a service charge of 25% added to the remaining balance and the account will be forwarded to our collection agency. Returned checks will be charged a service fee of $50.00.

All balances must be paid in full before materials can be released. We do not have a payment plan. We accept all major  for your convenience.

If we are not billing your insurance company, then payment for all services including: exams and/or contact lens evaluations are due at the time services are rendered.

By digitally signing your name below, you agree with the terms of this agreement.

  • Please type the full name of the patient or patient's representative.
  • MM slash DD slash YYYY