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GOULD EYE CARE ASSOCIATES

Sigmund S. Gould, M.D.
Jason A. Gould, O.D.

 
THIS FORM MUST BE SIGNED BEFORE TREATMENT IS INITIATED. THANK YOU.


Please remember that your insurance coverage is a contract between you and your insurance carrier.  It is a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment.  Some companies pay fixed amounts for certain procedures and others pay only a percentage of the charge.  It is your responsibility to pay the deductible amount or any other amount not paid for by your insurance.

 
If you are scheduled for a routine eye exam, it is your responsibility to know which insurance company your benefits are with, your copayment amount and if the doctor you are seeing is a participating provider.

 
In order to control our cost of billings, we request that our charges for office visits be paid for at the conclusion of each visit.

 
If this account is assigned to an attorney, as in a liability case, the patient is still responsible for payment of services rendered at the time services are performed.


PLEASE READ THE FOLLOWING AND SIGN BELOW:

 
I authorize disclosure of my medical records to my insurance company or attorney to facilitate payment and/or processing of my claim. I also authorize release of my medical history and/or records to any health care provider to whom I may be referred for a second opinion, for a consultation, for therapy or for treatment.  I also authorize obtaining my medical records from health care providers involved in my treatment.

 
I understand that I am financially responsible for all charges unless treatment is covered by a health maintenance organization or Worker’s Compensation insurance.

 
I hereby assign all insurance benefits, medical, liability or otherwise to Sigmund S. Gould, M.D., P.A. for any unpaid portion of my bill.

 
SIGNED:_______________________________DATE:____________________


I do consent to and grant permission for photographs or other visual aids to be taken during the course of my treatment and during any surgical procedures performed in the course of my treatment. This documentation will be used for medical purposes only and will not be used for advertising.

 
SIGNED:_______________________________DATE:_________________

WITNESS:______________________________

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