I understand and agree that by allowing Edgewater Eyecare, LLC to file insurance on my behalf does not absolve or excuse me from my financial obligations to pay for all services; and/or glasses or contacts my dependents or I may receive. Failure of my insurance company to make payment on my behalf, whether due to deductible, pre-existing conditions, non-covered services, or any other reasons for which payment is denied, will be PAID BY ME.
By my signature below, I have read and agree with the terms stated above. I authorize the release of any medical or other information necessary to process this claim. I authorize payment of medical benefits to be made directly to Edgewater Eyecare, LLC.
Accounts delinquent over 90 days will be turned over to Network Services Collection Agency. In addition to the amount owed to Edgewater Eyecare, LLC you will be responsible for paying fees to the collection agency as well.