Skip to main content

Walled Lake: 248-624-1707
South Lyon: 248-437-3351

Widget+Button

hero-childpage

Be Our Friend
Keep up to Date

Home » Patient Financial Information Sheet

Patient Financial Information Sheet

  • I understand that payment is due in full at time of service unless other arrangements have been made.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • I authorize the release of any information including the diagnosis and the 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 health practitioners.

    I authorize and request my insurance company to pay directly to the doctor insurance benefits otherwise payable to me.

    I understand that my insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY

Voted Best Eyecare in West Oakland County

We are back and seeing ALL patients!  We want to assure you that we take the health and well-being of our patients, staff, and community seriously.  We are taking all necessary precautions, as advised by the CDC, to prevent the spread of COVID-19.

Here are some ways we will promote the safety of our patients and staff:

eyecarelive logo