Office Business Policies & Assignment of Insurance Benefits
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I understand that exam fees are Non-Refundable.
I understand that Prescription Related office visits are included up to 90 days after exam. After 90 days
additional fees will apply. Any Non-Prescription Related reasons (eye infection, red eye, etc.) will be charged a
different fee regardless of time since exam.
I authorize Dr. Riolan Marbun, OD, PC to release and/or request any information required to process my
insurance claim(s). I also authorize my insurance benefits to be paid directly to Dr. Riolan Marbun, OD, PC. I understand I am
responsible to pay any of the following in advance: deductible, co-insurance, and/or any other balance not paid by my
insurance. I understand that if my insurance is not accepted, payment must be made at the time of service. If any services or
payments are denied by my insurance, I understand I will be responsible for the full payment of services within 30 days of
being notified by the office of Dr. Riolan Marbun, OD, PC.
Annual Recall Program
I authorize Dr. Riolan Marbun, OD, PC to preschedule my yearly exam and provide my name, address, phone
number, email address, and next appointment date(s) and time(s) to Target Optical for the purpose of
providing reminder calls, postcards, coupons, and product information, either directly from this office or
Target Optical. Reminder calls may be live or prerecorded. I understand that I may revoke this authorization at
any time by notifying the office of Dr. Riolan Marbun, OD, PC.
View HIPAA Notice
which describes how my health information is used and shared. I understand that the Office has the right to
change this Notice at any time. I may obtain a current copy by contacting the Office. I can be assured that my
personal health information will not be sold to a third party for such party's own use.