Policy Forms

Step 1 of 9 - Patient Information Acknowledgement - Optic Gallery Sahara

Patient Information Acknowledgement

In the event that it becomes necessary for us to release your records to or request your records from another healthcare professional, I authorize Optic Gallery, Dr. Cheung or any of her associates to release and/or request these records. If applicable, I request that payment of authorized Medicare or other insurance be made either to me or on my behalf to Optic Gallery, Dr. Cheung or any of her associates for any services rendered to me. I authorize pertinent medical information about me to determine insurance benefits and billing to be released to the health care financing or other insurance agencies. I understand that should my financial account become delinquent, it will be sent to collections where I will be responsible for any collections fees, attorney fees, and court costs. I UNDERSTAND I AM RESPONSIBLE FOR ANY CHARGES NOT COVERED BY MY INSURANCE COMPANY. It is the policy of this office to require: 1) Payment in full or at least one-half before the order can be placed. 2) The balance of the fee must be paid at the time the order is dispensed. 3) All orders are final when placed.
Patient Information Acknowledgement Consent.(Required)
Disclaimer: By typing your name here in this field, it will be an authorized signature
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