I authorize all persons listed below the ability to receive materials and or medical information on my behalf

(This information is kept strictly confidential. However, you may discuss this portion directly with the doctor if you prefer.)

Please note any family history for the following conditions and the relationship to the patient:

Thank you for choosing Family Eyecare to serve you and your family’s eye health needs. We are pleased to participate in your family’s health care and look forward to establishing a lasting relationship. We are committed to providing you with the best care available. The following financial policy is provided to avoid any misunderstanding and provide you with an outline of our expectations. Your insurance policy is a contract between you and your insurance company. Please note it is your responsibility to become familiar with your plan. You are expected to know if routine procedures are covered and the time-frame in which they are allowed. If you do not understand your specific plan coverage, please call your insurance company or your HR department at work. The number for your plan is listed on your insurance card. We can often help with providing information to assist in filing claims, but you are primarily responsible for any charges that you have incurred as a patient with Family Eyecare. Please review and sign the following financial policy prior to your office visit.

1. CO-PAYMENTS, DEDUCTIBLES, AND FEES – All co-payments, insurance deductibles, and fees for service not covered by your insurance policy are due at the time service is rendered. We make every effort to collecte balances up front. However, many fees will not present themselves until a final claim determination has been made by your insurance company. In those cases we will mail a statement to you for any outstanding balance. We accept cash, check, or credit cards (VISA, Mastercard, and Discover, Care Credit)

2. INSURANCE – Patients must complete and sign information and insurance forms prior to seeing the physician. You must present a current insurance card at each visit. If you or your children do not present a current insurance card, you will be responsible for payment at the time of your visit. You will receive reimbursement from Family Eyecare if your insurance pays the claim, at a later date. If your insurance carrier is not one with which we participate you are responsible for payment in full. Insurance plans and Medicare consider some services to be “non-covered,” in which case you are responsible for payment in full. You have a responsibility to provide information to our office so a claim can be properly submitted. If your insurance company has not paid a claim on your behalf within 90 days because of information that you have not provided the balance will be transferred to your account and you will be responsible for payment. If we receive payment at a later date, you will be reimbursed by Family Eyecare.

3. MINORS AND DEPENDENTS – The adult who brings a minor child into our practice accepts final responsibility for payment. We will send statements to the guarantor listed on your registration sheet, but time of service payment and final payment is the responsibility of the accompanying adult. Parents are responsible between themselves to communicate with each regarding treatment and payment issues. You will be able to receive a summary of each visit via the patient portal which may be used for parent communication.

4. PROMPT PAYMENT-Just as we make every effort to accommodate you when you are in need of medical care, we expect that you will make every effort to pay your balance promptly. If you have a financial hardship or if you are unable to pay your balance in its entirety please contact Family Eyecare to discuss payment options. We must have a signed payment plan and you must be paying regularly (each month) to keep your account from further action. If your account becomes delinquent and you have not established or met payment options with Family Eyecare, your account will be turned over to a collection agency and we will ask you to seek your medical care from another office.

By signing below, the responsible party acknowledges that he or she has read and understood the financial policy of Family Eyecare and is bound by its terms and conditions. You also understand that failing to sign this agreement may result in discharge from this practice.

1. Comprehensive eye exams include all professional services related to the evaluation and treatment of your eye and visual health. In particular, routine eye exams (i.e., presenting only with symptoms of blurred vision, without any acute/chronic eye health conditions/diseases) and refractions (i.e., the determination of your eyeglasses prescription) are usually covered by vision insurances, but NOT primary health insurances. (MEDICARE, for example, does NOT cover either, and they are considered out-of-pocket expenses A referral is not a guarantee of payment.

2. Treatment of eye diseases, either upon initial presentation or otherwise following the initial comprehensive eyeexam, is a separate billable service. While treatment of eye diseases is not covered by vision insurances, it is usually covered by primary health insurances, including MEDICARE.

If you have both types of insurance plans, it may be necessary for us to bill some services to one plan and other services to the other plan. We will follow a procedure called coordination of benefits to do this properly, in order to minimize your out-of-pocket expense.

3. Contact lens fittings are a separate billable service from comprehensive eye exams (although they may be rendered on the same day), and a comprehensive eye exam within one year is an obligatory prerequisite for your primary health insurance including MEDICARE. Any subsequent follow-ups to refine the contact lens prescription are included at no charge for up to 90 days, or up to five follow-up visits, unless otherwise stated at the time of examination.

I assign all of my medical benefits, including all benefits to which I am entitled through Medicare, private insurances, and any other health plans, to Family Eyecare. A photocopy of this assignment is to be considered as valid as an original. I authorize said assignee to release all information necessary to secure payment of benefits paid and not paid by my insurance company.

Benefits quoted to me are not a guarantee of payment by my insurance company, and final determination can only be made when the claim is processed. The patient is still responsible for the co-insurance, deductible, and any other non-covered services. The co-insurance and deductible are based upon the charge determination of the insurance carrier, which can only be confirmed after the claim has been submitted.

I understand that, if some fees are not paid by my insurance, I am still financially responsible and will be billed for them. Accounts 90 days old are subject to collections, and there will be a service charge of $20.00 for any bounced checks. I understand that it is MY responsibility to know my own coverage.

All sales of prescription and non-prescription eyeglasses and sunglasses are final. However, patients are welcome to return to the office as many times as needed before the decision to purchase is made. If there is a need for the prescription to be adjusted, such changes are included at no charge for a one-time redo within 90 days. If a satisfactory prescription has not been reached after the one-time redo a refund will be given for eyewear. If there are any discrepancies between the doctor’s prescription and the lenses manufactured by the lab, these changes will be provided at no charge. All of our lenses & frames have a warranty for any manufacturer defects for up to one year from the date of purchase, which does not include accidental damage from, for example, dropping your eyewear.

With regard to the sale of soft contact lenses, any unopened and unmarked boxes may be returned for a full refund, or exchanged, within 6 months of purchase.

All eyeglasses and contact lenses that have been prescribed, fitted, and purchased by the patient will be kept in the office for a total of one year from the date of purchase. If the patient does not pick up his/her eyeglasses or contact lenses within that year, we will subsequently donate them to charity.

Any bounced personal check are subject to a fee of $20.00, which is to be paid, in addition to the original amount on the check, within 90 days. After the 90 day period has expired the check will be turned over to the county attorney for collection.

I have read and understood all aspects of the above policies. It has been made known to me that, if any or all parts of the above policies are not fully understood by me, that further explanation is available and has been provided to me at the time of signing.