Please review and complete the following information.

 

Patient:
Birth Date:


I certify that I (or my dependent) have insurance coverage with (List both Vision and Health Insurances):


Vision Insurance(s):
Health Insurance(s):

I assign directly to Dr. Michelle T. Valella all insurance benefits, if any, for services rendered.  I understand that I am financially responsible for all charges whether or not paid by my insurance.  I, hereby authorize the doctor to release all information necessary to secure the payment of benefits.

 *********************                      

PLEASE TAKE NOTICE:
We are unable to predetermine professional service fees for your office visit until Dr. Valella has performed all necessary testing and procedures.  Fees for medical exams and tests range from $100-$500. Please be aware if we are billing your health or vision insurance for your visit(s), your insurance coverage is a contract between your insurance company and you-Not Us.  You are ultimately responsible for all insurance copay's/deductibles and fees in our practice.


 I agree to the above statements.

      

 If you are not willing to agree to the statements above, we will need you to pay for

your entire visit's fees upon check out, then we will bill any insurances you have.