PATIENT INFORMATION and FINANCIAL AGREEMENTPatient Information and Financial Agreement • October 28th, 2015
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ CREDIT CARD INFORMATION (REQUIRED): In the event your account becomes more than 30 days past due, I authorize Karina von Middendorf to debit my account for any unpaid fees that are considered my financial responsibility. Please print clearly and sign your authorization and agreement below.
PATIENT INFORMATION AND FINANCIAL AGREEMENT (PLEASE PRINT)Patient Information and Financial Agreement • March 14th, 2014
Yes No Yes No Heart Disease: Congestive Heart Failure (CHF) Valvular Disease High Blood Pressure Stents Heart Attack Arrhythmia Atherosclerotic Disease Coronary Artery Bypass Angioplasty Angina Do you have a Pacemaker? Vascular Disease: Chronic Obstructive Pulmonary Disease (COPD) Respiratory Distress Syndrome Emphysema Recent Pneumonia Peripheral Artery Disease Stroke/TIA Blood Pressure Meds Chronic Bronchitis Diabetes Hypertension Asthma General Medical Conditions: Arthritis (rheumatoid/osteoarthritis) Osteoporosis Allergies Anxiety or Panic Disorders Neurological Disease (such as MSor Parkinson’s) Kidney, Bladder, Prostate orUrination Problems Headaches Previous Accidents GI Disease (ulcer, hernia, reflux,bowel, liver, gall bladder) Visual Impairment (cataracts,glaucoma, macular degeneration)
PATIENT INFORMATIONPatient Information and Financial Agreement • September 29th, 2020
Out-of-pocket payments and copayments are due at the time of service unless there is a special arrangement defined ahead of time.
PATIENT INFORMATIONPatient Information and Financial Agreement • January 8th, 2021
River Region Vision Source Patient InformationPatient Information and Financial Agreement • July 24th, 2020
HIPPA Release: Please list persons that you will allow River Region Vision Source to release your medical and financial information
Patient InformationPatient Information and Financial Agreement • February 28th, 2019
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.
