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I request that payment under the medical insurance
program be made directly to Cochise Eye & laser on any unpaid bills for
services furnished me by Cochise Eye & Laser. I authorize the above named
provider to release any information to insurance carriers needed for this
claim. I further permit a copy of this authorization to be used in place of its
original.
IT IS UNDERSTOOD, I AM RESPONSIBLE FOR ALL FINANCIAL OBLIGATIONS of
health services, and for reimbursement and payment of claims from my insurance
company. I understand that payment is expected at the time services are
rendered unless other arrangements are made in advance. If for any reason the
account should become delinquent, I agree to pay for all rebilling
charges, interest charges, collection costs and reasonable legal fees. |
