*Please note text messaging and email is used to communicate with our patients for appointments and for health and safety protocol.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:
The undersigned patient or legally authorized representative of the patient acknowledges that they personally reviewed the Notice of Privacy Policies for W. Sam Shields, O.D., and Associates on the date indicated below. The Notice of Privacy Practices is posted on our website and is available in our office.
PLEASE READ AND ACKNOWLEDGE:
We ask that the patient’s portion be paid at the time the services are rendered unless other arrangements are made in advance. All professional services and material are charged to the patient. The undersigned will ultimately be responsible for any bill incurred in this office regardless of insurance. Accounts 90 days old are subject to collection fees. There will be a service charge for all returned checks.
Payment from my insurance is to be paid directly to Dr. W. Sam Shields. I understand that if I have listed a primary insurance provider above, it will be billed as my primary insurance. I understand that billing any secondary insurance is my responsibility. I understand that all benefits quoted to me are not a guarantee of payment by my insurance provider and that final determination can only be made when the claim is processed.
2812 Cochran Street, Simi Valley, CA 93065Phone: (805) 527-6164 | Fax: (805) 527-4391Email: firstname.lastname@example.org