All required payments, co-payments, deductibles, and other out-of-pocket expenses are due
in full at the time services are rendered or materials are provided, unless specific financial
agreements have been made prior to your scheduled appointment. The office accepts VISA, Master Card, AMEX
debit cards and personal checks with proper identification. All personal checks returned for any
reason are subject to a $25 service charge without exception. In the event of nonpayment, the cost of
collection and or court costs and reasonable legal fees is the responsibility of the patient.
It is your responsibility to understand the nature of your vision plan and insurance benefits prior
to your scheduled appointment. The employees of Carlsbad Optometry will, to the best of their knowledge
and understanding, help answer any questions you may have regarding your vision plan and insurance benefits;
however, no guarantee of accuracy regarding eligibility, coverage, or benefit information can be made by
anyone other than your vision plan or insurance carrier directly.
I authorize assignment of vision plan and insurance benefits to Carlsbad Optometry for the purpose of
determining eligibility, benefits, and collecting for all services rendered and materials provided. In
addition, I authorize Carlsbad Optometry and any of its employees to furnish information concerning my
present condition to insurance companies and referring doctors as deemed necessary.