ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY I authorize my insurance benefits be paid directly to Bowers Optometry, PA, on my behalf. I also authorize Bowers Optometry, PA, or my insurance company to release any information needed to process my claims. I understand that I am financially responsible for any co-pay, co-insurance, deductible, and other non-covered services or materials the day services are rendered. I also understand I am financially responsible for any balance remaining after my claim has been processed. Patient/Guardian signaturepatient’s name First Last Date MM slash DD slash YYYY OFFICE POLICIESWe request 24 hours notice to cancel or reschedule an appointment. We understand that emergencies do come up, so please call our office as soon as possible if you cannot keep your appointment so that other patients in need of care can be seen. We do charge $25.00 if less than 24 hours notice is given or you do not show for an appointment. We do charge a $25.00 fee for returned checks.