MM slash DD slash YYYY
MM slash DD slash YYYY
Insurance, Policies, and Procedures
There are two types of Insurance that may contribute to services performed today. Vision Insurance (VSP, Eyemed, Davis Vision, ETC. ), and Medical Insurance (BCBS, UHC, Select Health, ETC.) You may have one or both.
Vision Insurances cover routine wellness exams and hardware (contact lenses or glasses). They do not cover the diagnosis, treatment, or management of eye health problems.
A contact lens fit is considered elective and your Insurance will not cover that portion of the exam.
Medical Insurance can be used to help with management of medical eye care.
We will gladly bill one or both of your Insurances to help minimize your out of pocket expense.
If some fees are not paid by either Insurance you will be billed for those appropriate fees, such as co-pays or deductibles as per your Insurance plan.
We must have a copy of all insurance cards in order for services to be billed.
HIPAA Privacy Disclosure
Authorization to release information- I hereby authorize Clinton Family Vision to release any medical information that may be necessary for medical benefit or processing applications for financial benefit. This includes, but is not limited to, my Insurance Company, rehabilitation services, social security administration, and workers compensation.
Consent for treatment- I hereby authorize the practice to administer diagnostic and medical procedures as may be necessary for proper healthcare.
Payment Policy- I understand that I am responsible for all changes incurred. As a courtesy my insurance will be billed for me. I understand and accept that I am responsible for all changes not paid by my Insurance plans, which includes, but is not limited to copays or deductibles.
Authorization for Treatment and Financial Agreement
I authorize treatment for the above named person and agree to pay all fees and charges for such treatment. I agree to pay all charges shown on statements promptly upon presentment thereof, unless credit arrangements are agreed upon in writing. Charges shown on statements are agreed to be correct and reasonable unless protested within thirty days of billing date. Our staff will help with completetion of insurance forms as an accommodation and convenience to you without charge. IT IS THE PATIENT'S RESPONSIBILITY TO KNOW YOUR CONTRACT BENEFITS, ASSURE COLLECTION OF INSURANCE PAYMENTS TO US, AND TO NEGOTIATE WITH YOUR INSURANCE COMPANY OVER ANY DISPUTED CLAIMS. It is agreed that payments will be delayed or withheld because of any insurance coverage or the pendency of claims thereon, and all proceeds of insurance are assigned to this office where applicable, but without assuming responsibility for the collection thereof. All account balances thirty days or older will be subject to a finance charge of 1.5% per month (annual rate of 18%). A charge of $25.00 will be assessed to all returned checks. Should collection become necessary, the responsible party agrees to pay a collection fee of up to 40% and all legal fees of collection, with or without suit, including attorney fees and court costs.
Medical Information Release Form (HIPAA Release Form)
CONTACT LENS EVALUATION AGREEMENT
WHAT IS A CONTACT LENS EVALUATION?
A contact lens evaluation includes the following services provided by both the doctor and staff at Promontory Family Vision.
* Assessment of visual needs and expectations.
* Evaluation and determination of prescription and eye health in regard to contact lens wear.
* Diagnostic trial lens fitting.
* Follow-up examinations to monitor eye health, prescription accuracy and appropriate fit for a 90 day period, or depending on the complexity of the fit.
The evaluation fee includes the initial visit and all subsequent visits related to contact lens wear for a 90 day period, or depending on the complexity of the fit. The evaluation fee starts at $40.00. The follow-up period begins when the first contact lens is dispensed to the patient.
INSERTION AND REMOVAL TRAINING
In addition to the above evaluation fee, first-time contact lens wearers are scheduled for a training session with a contact lens technician when the trial lenses arrive. During this session, patients are taught how to insert, remove, clean and care for contact lenses. The session may take up to an hour and a half, depending on how quickly the patient becomes comfortable with insertion and removal of the lenses.
* Charges for Contact lens evaluation fees are due in full at the time of the contact lens evaluation.
* All contact lenses must be paid in full prior to being ordered.
* Progress checks and other contact lens-related services performed after the above mentioned follow-up period are subject to normal office visit charges.
* Most insurace plans do not cover the full amount of contact lens fees. You will be responsible for any uncovered costs incurred by the eye exam and contact lens evaluation or contact lenses.
* Professional fees for the complete eye exam and contact evaluation fees are not refundable.
* You are responsible for scheduling and attending follow-up visits in order to finalize your prescription. Your prescription will not be released and contact lenses will not be ordered for you until your prescription has been finalized by the doctor.
* Contact lens prescriptions expire after 1-2 years.
* We can provide your contact lens prescription if:
-You have had a contact lens exam within the last 12 months at Clintion Family Vision.
-You have returned for all requested follow-up exams, allowing the doctor to finalize your prescription.
-An ocular medical condition does not exist requiring follow-up care.
-All financial obligations have been met.
MM slash DD slash YYYY