Financial Responsibility & Payment Authorization Policy 

By scheduling an appointment or receiving services at Eyes First, I acknowledge and agree to the  following terms: 

1. Patient Financial Responsibility: I understand that I am financially responsible for all charges associated with services provided  to me, including copays, deductibles, coinsurance, non-covered services, services denied by my  insurance carrier, and balances remaining after insurance processing. Insurance is a contract  between me and my insurance company. Filing insurance claims is a courtesy provided by Eyes  First. Final responsibility for payment rests with me. 

2. Payment at Time of Service: Payment is due at the time services are rendered. 

3. Card-On-File Authorization: I authorize Eyes First to securely store my credit or debit card information on file and charge my  card for balances due, no-show fees, and installment payments. 

4. No-Show and Same-Day Cancellation Fee: A $30 fee applies. 

5. Payment Plans & Recurring Charges : Balances unpaid after 90 days may be placed on a no-interest 6-month plan. I consent to  recurring charges. 

6. Notices: Notices may be sent by mail, email, phone, text, or portal. 

7. Insurance Denials: I am responsible for remaining balances. 

8. Collections: Unpaid balances may be sent to collections.