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Home » Contact Us » Acknowledgment of Notice of Privacy

Acknowledgment of Notice of Privacy

  • Click to Read Our Privacy Policy
  • I authorize Parkland Eye & Vision Clinic, PLLC to release my personal health information to the following individuals:
  • I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY

  • Date Format: MM slash DD slash YYYY

  • If you are signing as a personal representative of the patient, please indicate your relationship. If you are signing for a minor, you attest that you have legal authority to make medical decisions for the minor.
  • Date Format: MM slash DD slash YYYY
  • Financial Policy

  • Insurance

    Parkland Eye & Vision is not responsible for charges NOT covered by your insurance company.

    • Insurance cards must be presented along with necessary forms at time of appointment
    • We cannot guarantee the accuracy of information given by insurance companies regarding coverage.
    • It is the patient’s responsibility to determine whether insurance company covers services rendered.
    • We will bill your insurance if we are a participating provider for your program.
    • We may bill your vision, medical insurance or multiple plans depending on coverage policies and your vision or medical condition(s).
    • If we are not a participating provider, upon payment at time of service, you will be provided with paperwork to submit to your insurance company for reimbursement.
    • You will be billed for all charges not reimbursed by your insurance company.
    • Deductibles, co-payments and non- covered professional services or materials are due at the time of service or when materials are ordered.

  • Payment

    Payment is due in full at time of service. We accept cash, check, Visa and MasterCard.

    • Payment for all prescription devices, lenses, contact lenses and materials must be made beforeorders are placed.
    • Orders are processed at time of full payment.
    • Order cancellations must be made before close of that business day. Cancellations after this time are subject to charges.
    • Eyeglasses are custom ordered per patient and therefore all frame sales are final and cannot be exchanged or refunded.
    • Account balances over 30 days will receive a finance charge of 1.0% per month (12% APR).
    • Checks returned for insufficient funds will incur a fee of $40 in addition to the amount due.
    • Accounts not paid in full within 150 days are automatically placed with an outside collection’s agency
  • I understand that I am responsible for the balance on my account for services rendered and/or materials purchased.
    If delinquent balances are referred for collection, I agree to pay all costs and attorney’s fees.
    I authorize that my insurance payments are paid directly to Parkland Eye & Vision.
    I authorize use of this signature on all insurance claims.
    I also authorize release of records to my insurance company as needed.

    I have read and agree to the Financial Policy of Parkland Eye & Vision Clinic, PLLC. This agreement remains in effect until revoked by me with written notification to Parkland Eye & Vision Clinic, PLLC

  • Date Format: MM slash DD slash YYYY

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