Office Policies Consent Form Office Policies and Patient Financial Responsibility Disclaimer Consent form Date(Required) Year Month Day Name(Required) First Last Consent(Required) I agree to the Office Policies and Patient Financial & Responsibility Disclaimer (opens in a new tab).By submitting this form in lieu of signing the above-mentioned Office Policies document, I acknowledge that I have read the information and understand it, as well as my responsibilities as a patient of Triangle Family Eye Care, completely. In addition, if any payment is denied, I agree to be personally and fully responsible for the payment within two months (60 days) from the date of service. Any balance deemed patient responsibility, and which remains unpaid after two months of invoices (60 days), will begin various collections activities including, but not limited to, submitting the past due account to a collection agency and adding collection fees. Δ
