FINANCIAL DISCLAIMERS

Eligibility for medical insurance and/or routine vision benefits:

We will attempt to verify your plan eligibility for services and/or materials before your appointment. Verification of eligibility is done as a courtesy only and is not a guarantee of payment. Please check with your plan administrator if you have any questions regarding your eligibility, and to confirm our doctors participate in your plan. It is your responsibility to obtain any referrals needed and to make us aware of any insurance changes.

Liability:

I understand that the account balances and co-payments are due at time of service. If I have medical insurance or routine vision benefits, I authorize my plan carrier to directly pay Koetting Eye Center. I also authorize Koetting Eye Center to release any information required for payment to be made. If my plans carrier does not, or partially pays, I understand that I am responsible for payment in full or the remaining balance. Balances 60 delinquent, after insurance payments, may be sent to a collection agency. My signature below verifies that I understand this agreement and the above financial disclaimers.