Daynes Eye and LASIK Conditions of Service
1. CONSENT TO TREATMENT: I hereby consent to any laboratory procedures, medical treatment or
facility services rendered to the patient under general and special instructions of the attending physician.
2. RELEASE OF INFORMATION: Subject to State and Federal regulations (42 C.F.R. part II), this facility
and/or Physician Billing Service may disclose all or part of the patient’s record for this service to any
person or corporation which is or may be liable under a contract to the Physician, or to a family member
or employer of the patient for all or part of the provider’s charges, including, but not limited to hospital or
medical service companies, insurance companies, worker’s compensation carriers, welfare funds and all
authorized auditors as specified in the Insurance Carrier Guidelines and referring professionals.
FINANCIAL AGREEMENTS
I hereby certify that the information provided herein is correct.
I understand that I am responsible for full payment of all charges incurred with this service and I agree to
make full payments for such charges by cash and/or by payment from assigned insurance benefits. I
understand that all charges not covered by insurance are due in full at time of service.
In the event that full payments for charges incurred in above are not made as agreed upon above, I
agree to pay delayed payment fees at the rate of 1 ½% per month/18% per year on any unpaid balance and
to pay all costs and expenses incurred in collection of and said charges, including reasonable attorney’s
fees and collection expenses. I hereby consent and submit to the jurisdiction and venue of the courts of
the State of Utah, County of Service, for the purpose of such action.
CHECK AGREEMENT: I hereby agree to pay a service charge for each check or other instrument tendered
by me but returned to the facility. I further agree to pay all costs and expenses, including attorney’s fees,
that incurred in collection on such a returned check, draft, or money order.
MEDICARE/MEDICAID PATIENTS CERTIFICATION: I certify that the information given by me in applying for
payment under Titles XVIII and XIX of the Social Security Act is correct. I authorize any holder of medical
or other information about me to release to the Social Security Administration or its intermediaries or
carriers any information needed to process any claim on this or any related service. I request that
payment of authorized benefits by made in my behalf directly to this facility and/or Physicians Billing
Service for its charges and for any charges of Physicians for whom the facility is authorized to bill in
connection with its services.
CHAMPUS/CHAMPVA AUTHORIZATION: I request payment of authorized benefits to this facility on my
behalf for any services furnished me by this facility including Physicians’ services I authorized to bill in
connection with its services.
ASSIGNMENT OF BENEFITS: I hereby assign and transfer to this facility and/or Physicians Billing Service
all insurance benefits payable to me by my insurance company(s) (and other policies, if any) for services
and costs incurred in connection with this service. I understand this assignment of benefits shall be
exclusively for the payment of charges for this service. I understand this assignment of benefits shall be
made by my insurance company to the facility and/or Physicians Billing Service. I understand that I am
financially responsible for charges not covered or paid by my third party sponsor which may include, but
are not limited to: telephone calls, reports requested by the patient, insurance carriers, or employers and
appointments not canceled at least 24 hours in advance.
RECEIPT AND ACKNOWLEDGEMENT OF PRIVACY PRACTICES: I hereby declare that I have read and
understand the facility’s Policy of Privacy Practices.
RELEASE OF INFORMATION: I hereby authorize above named facility to release to my insurance company
any information concerning and procedures performed during this treatment and the final diagnosis, as
well as information contained on this form.
RELEASE OF ACCOUNT INFORMATION: I understand any individual listed on the front of this page and any
individual who can reasonably assumed to will be authorized to retrieve any and all information
pertaining to this account. This can include, but is not limited to, medical information relating to any
person listed on the account as well as financial information and transactions. Furthermore, if there are
individuals whom I do not want authorized to access information, I will notify the facility HIPAA Compliance
Officer in writing.
DAYNES EYE AND LASIK CONDITIONS OF SERVICE