Common Contracts
1 similar Patient Information and Financial Agreement contracts
Premier Eye Care Patient Information and Financial AgreementPatient Information and Financial Agreement • June 12th, 2017
PAYMENT TERMS: We are happy to assist you in the filing of your insurance claim. If your insurance will not pay for the anticipated services and materials or your insurance pays you directly, we ask that you pay the balance. Office policy calls for payment of all doctor’s fees at the time of service. If eyewear or contact lenses are to be ordered, a minimum of 50% deposit is required and the balance is due upon delivery. We accept cash, personal check, debit cards, flex spending account cards, VISA, Master Card, American Express and Discover. A 1.5% finance charge will be added to any accounts with an unpaid balance after 30 days, as allowed by South Carolina law. Patient agrees to pay all court cost, attorney’s fees and other expenses if account is sent to collections.
