Eyes on Main Welcome Consent Form

I authorize Lakeshore Professional Eyecare / Eyes on Main / West Ottawa Eyecare to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such eye care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to Lakeshore Professional Eyecare / Eyes on Main / West Ottawa Eyecare. Vision plans only cover routine vision wellness exams, along with eyeglasses and contact lenses. Vision plans do not cover medical eye care (the diagnosis, management or treatment of eye health problems). Medical insurance must be used for medical eye care. I understand that if I have both types of insurance plans it may be necessary to bill some services to one plan and some services to the other, using a procedure called coordination of benefits to do this properly and to minimize out-of-pocket expense. I understand that if fees are not paid by my insurance, I am still responsible and will be billed for them. Accounts 90 days old are subject to collections, and there will be a service charge for any bounced checks. I understand that if I do not show up for an appointment on two occasions or reschedule an appointment on short notice twice in one year, I may be discharged as a patient at LPE’s discretion.