New Patient Registration Form

AUTHORIZATION AND INSURANCE ASSIGNMENT
I hereby authorize Bethel Vision Care to apply for benefits on my behalf for covered services rendered. I request that payment from my insurance company be made to the above-named provider. I certify that the information I have reported with regard to my insurance coverage is correct and further authorize the release of any information to my insurance company in order to determine insurance benefits to which I may be entitled. I also authorize the release of my medical information to any physician or facility to which I am referred for diagnostic testing or other services necessary to my treatment. I may revoke this authorization at any time in writing.

FINANCIAL AGREEMENT
I understand and agree that, regardless of my insurance status, I am responsible for my account, have read and completed all the information on this sheet, and certify it to be true to the best of my knowledge, and I will notify the office of any changes. In the event my account is forwarded to collections due to lack of payment, I will be responsible for any collection and attorney fees.