Financial Arrangments
Payment of the "patient responsible" portion of the bill is required BEFORE services are rendered. SEECA offers the following payment options: cash, check, ATM/debit cards, major credit cards, and payment plans. If you wish, we can set up an interest-free payment plan for you (pending credit approval) through Care Credit. SEECA is unable to provide service if the above criteria are not met, except in an emergency. By signing below, you authorize your insurance company to pay SEECA directly, realizing that your insurance carrier may pay less than the billed amount for the services provided. By signing below, you agree to be ultimately responsible for payment of all services provided to you and your dependents.

Disclaimer
According to the Physician's Desk Reference, patients should not drive or engage in hazardous activities while their pupils are dilated. Patients should protect their eyes from bright light when dilated. If you are scheduled for dilation, please have someone available to drive you home, and ask for a free pair of sunglasses, if you do not already have a pair. You may ask for reversal drops to help diminish the effects of dilation after your visit. By signing below, you affirm that you have read and understand the above information and release SEECA from any liability related to dilation.

Authorization
I authorize the release of the following information to third party payers, and health care providers: the medical chart, account data and any other information associated with care provided to my child or me by SEECA.