Only fill out this section if you are answering on behalf of patient.

Payment is expected at the time of service unless we are a provider for your insurance company. It is our policy that all co-pays and/or deductible amounts are due and expected at the time of service.

I authorize Dothan Eyecare, to release any medical information requested by my health insurance carrier, Medicare or any other third-party payers. Dothan Eyecare, may contact my insurance company or health plan administrator to obtain pertinent financial information concerning coverage and payments under my policy. I hereby authorize payment of insurance benefits be made on my behalf to Dothan Eyecare, and assign benefits to the physician indicated on the claim. I understand that I am responsible for any co-pays or deductibles as defined by my insurance policy, and for any "non-covered" services of my consent if deemed necessary. I accept the fee charged as a legal and lawful debt and agree to pay said fee, including any/all costs of collection, attorney fees, and/or court costs; if such be necessary. I waive now and forever my rights of exemption under the laws of the constitution of the State of Alabama and any other state. I give Dothan Eyecare, its employees and/or agents "express prior consent" to contact me at any/all phone numbers, including cellphone numbers (by phone call or text message) for the purpose of treatment, insurance or payment. I authorize Dothan Eyecare, to release all information to my referring physician and/or primary care physician. I hereby give authorization for treatment to my physician(s) at Dothan Eyecare, and give permission to disclose my protected health information in order to carry out treatment, payment, and other healthcare operations.

I, the undersigned, on behalf of the patient whose name appears above, consent to, and authorize all diagnostic and therapeutic treatments deemed necessary by the attending physician, or his staff, in accordance with today's medical standards and consent for future treatment may be revoked in writing and will not be revoked by implication. I have been offered a copy of the Privacy Notice for Dothan Eyecare. The following people are authorized to receive medical and billing information concerning my treatment with this facility.

I authorize and request that payment of any and all insurance benefits be made to Brent McKinley, M.D. and Arie J. Aldridge, M.D. I authorize Brent McKinley, M.D. and Arie J. Aldridge. M.D. to release to my insurance company and its agents any information requested to determine benefits or benefits payable. Due to the constant changes in insurance. it is not possible for Brent McKinley, M.D. and Arie J. Aldridge, M.D. to interpret each patient's individual policy. It is your responsibility to know your individual coverage. We will be glad to assist you with determining benefits but the final responsibility belongs to the patient. All accounts are subjected to an interest fee of I .5% monthly. 18% a nnually for unpaid balances. Any account turned over to collections will be assessed all fees from the collection agency. as well as any attorney fees and, or court cost. If you should need to cancel or reschedule an appointment, we ask that you call 24 hours prior to your appointment time. There is a $15.00 fee for missed appointments. After three missed appointments, a patient may be dismissed from the practice for non-compliance. There is a $15.00 fee for completin2 anv forms other than those required for processing any claims filed by Brent McKinley, M. D. and Arie J. Aldridge, 1\1.D. to your insurance carrier. Ex: FMLA. personal policy claims. personal disability forms. Returned checks: There is a $30.00 fee for a check that is returned.

List all surgeries you have had

Include any vitamins or non-prescription medicines