Eye Physicians of Orange County

Eye Physicians of Orange County, PC

1 Hatfield Lane, Suite 3

Goshen NY 10924

845∙294∙5128

845∙294∙1479 (fax)

8 Forester Avenue
Warwick, NY 10990

845∙987∙1203

845∙987∙1587 (fax)

845 Rt. 17M

Monroe, NY 10950

845∙782∙0129

845∙782∙3619 (fax)

Please be informed that due to the increasing cost of generating and mailing billing statements, we will no longer routinely send patients a bill for our services.

· You will be expected to pay for today’s visit. If you are unable to pay today, you will be given a statement, which is to be paid within 10 days of your visit.

· If we are forced to send you a bill, there will be a $5.00 surcharge added to your balance for each statement we must send.

· If after 30 days your balance is not paid, your account will be sent to a collection agency. There will be a collection fee of 50% of the total amount being billed, added to your balance to cover legal and collection fees.

I have read and understand the contents of this letter.

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Patient Signature

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Date