New Patient Intake Forms

The law requires the Corinth Eye Clinic, Inc/Weeden Eye Clinic make every effort to inform you of your rights related to your personal health information. By my signing below, I acknowledge that: I have been given the opportunity to read, have read , or had explained to me prior to any services offer Corinth Eye Clinic, Inc's Notice of Privacy Practice and agree to continue my care with Corinth Eye Clinic under said terms. By submitting this form I authorize the release of information about my health and/or appointments to the following people who are not my doctors or insurance providers. This digital signature is also my authorization for the release of information to process my insurance claim. I hereby authorize payment to this doctor of office named of the benefits otherwise payable to me. This signature may be used for all insurance claims unless revoked in writing.

We make every effort to keep down the cost of your medical care. You can help by paying in full upon the completion of each visit. If you have any vision and/or medical insurance we will be glad to fill out the proper forms or file the claim for you, but please complete the identifying information within this paperwork. If you are using insurance coverage for today's visit--this is a contract between you and your insurance company, not Weeden Eye Clinic, Inc., or Dr. Michael Weeden. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures or items and others pay a percentage of the charge. It is your responsibility to know the terms and limitations of your policies. For patients with BOTH medical and Vision coverage, your vision insurance is intended to provide you with a baseline eye exam. If you are being evaluated for medical reasons (corneal disorders, diabetes, cataracts, glaucoma suspect, double vision, etc.), you are being provided with medical care. Typically your vision company does not provide coverage for medical care. Therefore, we will file a claim with your medical insurance for visits related to medical complaints and problems. I certify that the insurance information that is on this form or provided to this office is accurate. I understand I am financially liable for any deductible amount, co-insurance & non-covered services or any other balance not paid by my insurance company(s). I understand that you may bill me if my insurance company takes longer than 90 days to pay your office. If my insurance company denies payment, I agree to be personally responsible for payment. If I have no insurance, I understand that I am responsible for the entire balance of services and products provided. I will be responsible for all collection costs, attorney’s fees, and court costs should my account be turned over to collection. I certify that I understand there are no refunds or exchanges and that all sales are final unless covered under manufacturer or office warranty programs.