At Haight Street Eyecare, our goal is to provide ocular health care that exceeds the standards of our peers. We will provide this care in the most courteous, cost effective, and conscientious atmosphere. It is important that you are involved in your care. This involvement starts with a clear understanding of our office policy that all payment is due on the day services are rendered.
I have received the Notice of Privacy Practices and have been provided an opportunity to review it.
I agree that Haight Street Eyecare may communicate with me electronically at the email address and phone number above. I am aware that there is some level of risk that third parties may be able to read unencrypted emails. I can withdraw my consent to electronic communications at any time.
Time has been specifically reserved for my appointment. Appointments must be cancelled at least 48 hours prior to appointment or a $60 fee will be applied. Monday appointment cancellations must be made by the prior Saturday by 2:00PM.
As a courtesy, Haight Street Eyecare will process insurance claims on the patient's behalf and help the patient estimate the covered benefit amount. I acknowledge that any amount not paid by my benefits plan is my responsibility.
Haight Street Eyecare has permission to bill for any outstanding balance on my account.
I certify that all information is complete and accurate. I authorize Haight Street Eyecare to collect payment as noted above. By signing below I certify that I am the authorized signer and will be responsible for all charges authorized by this form.