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Insurance & Payment Information

  • Please complete this form before your scheduled appointment.

    This information will help us serve your eye care needs more effectively and efficiently. If you have any questions at any time, please feel free to call us.

  • Primary Insurance

  • MM slash DD slash YYYY
  • Secondary Insurance

  • MM slash DD slash YYYY
  • Payment

  • Payment is expected as services are rendered. A service charge of $5.00 is added to all balances not paid within 30 days of the billing date. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect this balance or any future outstanding account balances.

    I authorize the release of any information including the diagnosis and records of any treatment or examination rendered to me or my child during the period of such care to third-party payers and/or other healthcare practitioners. I authorize and request my insurance company to pay directly to Della Porta Eyecare, LLC. insurance benefits otherwise payable to me. I also authorize Dr. Della Porta to initiate a complaint to the Insurance Commissioner for any reason on my behalf.

    In the event that this claim is denied by my insurance company, I agree to pay the full amount not covered within thirty days of such denial.

  • MM slash DD slash YYYY
  • Personal Informations

    All information is strictly confidential.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Responsible Party

    Who is responsible for the payment of this account?
  • MM slash DD slash YYYY
  • Telephone

  • :
  • Whom should we contact in case of an emergency?

  • This field is for validation purposes and should be left unchanged.