All patients MUST agree to the following statements or Family Vision Care of Ponca City will not be able to provide care.
I fully agree and understand that payment is due at time of service. I fully agree that I am responsible for all services and co‐payments not covered by my insurance company (should that apply). Financial arrangements, if needed, should be made prior to treatment. I hereby authorize release of information for insurance claim purposes.
I authorize Family Vision Care of Ponca City or their representatives, including collection agencies, to contact me via cell phone, email, or wireless device (including use of automated dialing equipment) regarding my account should it become delinquent. I understand that I may withdraw my consent to call my cell.
I fully agree and understand that payment is due at time of service. I fully agree that I am responsible for all services and co‐payments not covered by my insurance company (should that apply). Financial arrangements, if needed, should be made prior to treatment. I hereby authorize release of information for insurance claim purposes.
I authorize Family Vision Care of Ponca City or their representatives, including collection agencies, to contact me via cell phone, email, or wireless device (including use of automated dialing equipment) regarding my account should it become delinquent. I understand that I may withdraw my consent to call my cell.
