Skip to main content
Call Now! 201-464-3855
Schedule An Appointment

Advanced Family Eyecare, LLC – Dr. Simki Shah, OD

Menu
Purple-Magnolia-Trees-1280x853
eye-drops-blues-aqua-1280x480
kids-catch-ball
love.png
vegetables-791892_960_720
Home » INSURANCE INFORMATION AND COLLECTION POLICY

INSURANCE INFORMATION AND COLLECTION POLICY

  • PRIMARY INS

  • SECONDARY INS

  • I hereby authorize Dr. Simki Shah (Advanced Family Eyecare, LLC) to release any information acquired in the course of my examination of treatment.
    I hereby assign to Dr. Simki Shah (Advanced Family Eyecare, LLC) all money to which I am entitled for medical and/or surgical expenses, but not to exceed indebtness to Dr. Simki Shah (Advanced Family Eyecare, LLC). It is understood that any money received from my insurance company over and above my indebtness will be refunded to me when my bill is paid in full. I understand that I am financially responsible to Dr. Simki Shah (Advanced Family Eyecare, LLC) for charges not covered by this assignment.
    I understand I am responsible for any copay and deductible as per my insurance.
    We appreciate outstanding balances to be paid promptly. We will be adding 1½% interest per month for balances over 60 days and there will be a 25% surcharge for accounts referred to a collection agency.
x

We will be closed Friday, July 5.