Patient Registration Form

Patient Information

Responsible Party (if other than patient)

Insurance Information

Emergency Contact Information

AUTHORIZATION AND INSURANCE ASSIGNMENT

I hereby authorize Capital Eye Consultants to apply for benefits on my behalf for covered services rendered. I request payment from my insurance company to be made to the above named provider. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any information to my insurance company in order to determine insurance benefits to which I may be entitled. I also authorize the release of my medical information to any physician or facility to which I am referred for diagnostic testing or other services necessary to my treatment. I may revoke this authorization at any time in writing.

CANCELLATION POLICY

Capital Eye Consultants is committed to providing all of our patients with exceptional care. When a patient cancels without giving enough notice, they prevent another patient from being seen and, therefore, we do have a cancellation policy in effect. We greatly appreciate your consideration by notifying us as far in advance as possible, however, you are required to give this office a minimum of one business day (24 hours not to include weekends or holidays) notice prior to the scheduled appointment. Failure to comply with this office policy will result in a $40 cancellation fee, which must be paid before further treatment is performed (this is also applicable to no-showing). This fee is not covered by any insurance. By signing below you are agreeing to abide by this cancellation policy and to take personal financial responsibility for the cancellation fee should you violate this agreement.

FINANCIAL AGREEMENT

I understand and agree that, regardless of my insurance status, I am responsible for my account, have read and completed all the information on this sheet and certified it to be true to the best of my knowledge, and I will notify the office of any changes. In the event my account is forwarded to collections due to lack of payment, I will be responsible for any collection and attorney fees.

PAYMENTS

I agree and understand that I am personally liable to the medical service provider for payment of any balance on my account or on any account for which I am responsible for myself or as a parent or guardian (which may include professional service fees, missed appointment fee of $40.00, bounced check charges, etc.) regardless of whether insurance benefits have been applied for or received, including interest on any outstanding balance(s) at the rate of 18% per annum accruing 30 days after services are rendered and for any and all collection costs or fees, including but not limited to, 50% attorney’s fees and court costs if the account(s) is/are turned over to a third party and/or attorney for collection. I agree and understand that if I do not dispute in writing the amounts and charges set forth in any statement within 30 days after its issuance date that I am agreeing that the amounts and charges set forth in any statements are fair, reasonable and accurate. I agree and understand that if I file an action/counterclaim against the medical service provider/practice and the medical service provider/practice incurs any costs and attorney’s fees for its/their defense, I am liable for such costs and attorney’s fees if the medical service provider/practice is the prevailing party in said proceeding, which shall include, but not be limited to, bankruptcy, arbitration, mediation, litigation or other processes.