Monthly Bills

Monthly Household Income

I understand that this form will be used to evaluate my ability to pay my medical bill.  I agree to cooperate with McFarland Eye Care in pursuing reimbursement from any available insurance or medical payment programs and verifying the information on this form.  I understand that all or part of my indebtedness to McFarland Eye Care may be reduced if I qualify under the current The Clear Vision Project guidelines.  I understand that if I am not approved, I will be responsible for all patient balances.  I understand that I will not be eligible for benefits under the program until approval and that benefits may be approved retroactively only in the case of certain emergent cases needing immediate treatment.  I understand this is a voluntary program and is not required by any governmental mandate or regulation.

I hereby certify that the information contained on this questionnaire is correct and accurate, and I hereby authorize any and all parties to release any information necessary to confirm the information on this questionnaire including the amount of my assets and income.  I further authorize and agree that McFarland Eye Care may obtain my credit reports as part of the verification process.

Applications that are not completed in their entirety will not be processed.

If you have any questions or need help completing this form, please call (501) 503-4100.

By submitting this form, you agree to all statements within.