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Financial Responsibility Statement/Authorization to Release Medical Information

Your insurance is a method for you to receive reimbursement for fees you have paid to our office for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based on your contract with them, not with our office. It is your responsibility to pay in advance for deductible, coinsurance, or any other balances not paid for by your insurance. We will assist you in receiving reimbursement as much as possible, but you are responsible in advance for your bill.

A finance charge of 2.5% per month will be applied to any unpaid balance after 30 days. If payment is not made in a timely manner and should this office find it necessary to place your account with an agency for collection, you agree to pay collection fees of 50 % of the amount owed at the time of placement. In addition, you also agree to pay and all court costs and attorney fees at the rate 33.3% or $75.00 whichever is great, on any balance due and owing.

We will do our best to ensure your vision materials are manufactured to your specifications. However, if this does not occur, we will be glad to provide you with an office credit to be used anytime by you or your dependents. We do not refund fees for examinations or materials.

I authorize Dr. Lawrence Breaux and Family Vision Clinic to release to the necessary health care providers and agencies any information needed to determined services required or the benefits payable for related services. This assignment will remain in effect until revoked in writing. A photocopy of the assignment is considered to be as valid as the original.

Patient’s Signature


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