All information provided by you is strictly confidential and will not be shared. The only information
that is shared is the basic minimum required by your insurance company to pay your claim.
I hereby authorize Louisiana Eye & Laser Center to furnish the insured’s
insurance company all information which said insurance company may request
concerning my present illness or injury. I hereby assign to the doctors all
money to which I am entitled for medical and/or surgical expenses relative to
the services performed. It is understood that any money received from the above
named insurance company over and above my indebtedness will be refunded to me
when my bill is paid in full. I understand that I am financially responsible for
all charges, I hereby authorized Louisiana Eye & Laser Center to provide
such medical services including surgery, if necessary, either regular or emergency,
as may be determined to be in the best interest of the patient listed above. This
authorization shall continue and remain effective until revoked in writing by me.
The signature below serves as authorization for Louisiana Eye & Laser Center
to release or receive medical information for the purpose of patient referral.
A copy of this signature is as valid as the original.
Refraction is the process of determining the eye’s refractive error, or need
for corrective spectacle and/or contact lenses. It is an essential part of an
eye examination, but is not a covered service by Medicare or most insurances.
A fee of $35 for the refraction will collected in addition to any co-payment
I have read the above information and understand that the refraction is a
non-covered service. I accept full financial responsibility for the cost of
this service. The co-payment is separate from and not included in the refraction fee.
I have reviewed the Louisiana Eye & Laser Center Privacy Practice Notice that
describes how information about me may be used and disclosed. At my request, I
can receive a copy of this notice.
I hearby authorize the physician and/or such assistants as may be designated by
him/her to administer dilating eye drops. I understand that these eye drops are
necessary to diagnose my condition. I will need to wear sunglasses (available
at checkout) due to sensitivity to light. More information about the drops and
safety after dilation is available upon request.
(318) 487-2020 / 1-877-861-7770
231 Windermere Boulevard Alexandria, LA 71303
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