Crown Point Eye Care

Step 1 of 2

Financial Agreement, Consent to Treatment, and Privacy Acknowledgement

Insurance
You may have both vision and medical insurance. It is important that you understand that vision insurance does not cover medical eye problems, and that most medical insurance does not cover routine vision problems. Vision Insurance covers routine exams only and may help pay for glasses or contact lenses. Medical Insurance covers exams where any medical condition that can affect the eyes is evaluated. Examples of these conditions includes diabetes, high blood pressure, dry eyes, and cataracts.
After your examination, the doctor will determine to which insurance the exam must be filed. We are a provider on most major vision and medical insurance plans. If we are a provider for your insurance, we will file a claim to your primary insurance carrier. In the event we are not on your provider’s panel, we will provide an itemized receipt so that you may file the claim yourself. If you have a secondary insurance, and the co-pays or co-insurance is not automatically transferred, you will receive a statement and you must file the secondary claim. The balance on that statement is your responsibility. Crown Point Eye Care cannot provide a secondary claim filing service. Your complete insurance information/card must be presented at the time services are provided and updated as necessary. Accurate and complete insurance information must be provided so we may assist you in filing your claim promptly.

Financial responsibility
You will be responsible for any co-pays, co-insurance, or unmet deductible that your insurance carrier deems patient responsibility. You are also responsible for any non-covered services. Our office does not make these rules; they are defined by the insurance carriers themselves. We are contractually obligated to collect your portion of the fees as indicated by your insurance carrier. It is your responsibility to know your insurance benefits and coverage. Any dispute of coverage needs to be handled through the insurance company directly by you.

Materials
You are required to make payment for at least 50% of materials at the time materials are ordered. If you are supplying your own frame, you understand that many plastic and metal products may weaken over time and you will not hold Crown Point Eye Care or your insurance carrier responsible for accidental laboratory breakage. If you do not pick up your materials within 60 days from your initial order, your materials will be returned to the laboratory, and your initial deposit will not be refunded.

Returns / Refunds
Frame: If you are dissatisfied with your frame purchase, you can exchange for a new frame within the first 2 weeks from the date of purchase. You will be responsible for charges associated with upgrading to a more expensive frame. If you choose a less expensive frame, you will be refunded the difference in frame price.
Lenses: If the lenses are not yet in process in the lab, the original lenses will be refunded in full. If the lenses are already in process in the lab, you will be responsible for 100% of the cost of the lenses since they are custom.
Complete pair: the above policies apply. If you choose to switch to a new frame and the original lenses have already been edged, we will grant 50% off a new pair of lenses to fit the new frame. The original lenses and frame must be returned to the optical.

Returned Checks & Past Due Accounts
There is a $35.00 fee for any checks returned by the bank. Unless prior arrangements have been approved in writing by our office, the balance on your statement is due and payable when the statement is issued. An interest rate of 1.5% per month may be charged on any balance that goes beyond 60 days. If necessary, accounts that are not paid within ninety (90) days may be referred to a collection agency. If your account is turned over to collections, the responsible party(ies) will be responsible for all cost of collections, including court costs and attorney fees.

CareCredit: A convenient alternative to credit cards, cash or checks, CareCredit is a health care card that is exclusively utilized for medical services. They offer flexible payment options that fit your timetable and budget. For additional information, contact us or visit www.carecredit.com

Authorization to Bill: I have read and understood the above information and agree to comply with these terms. I authorize my insurance company to make payment directly to Crown Point Eye Care and its clinics for services and/or materials rendered. I authorize Crown Point Eye Care to release information about me or my dependents necessary to process any and all claims for reimbursement on my behalf. Yearly deductibles cannot be waived at any time by the provider of service or Crown Point Eye Care.

Authorization to Treat: I also authorize Crown Point Eye Care, its agents, and employees, and their agents and employees (collectively referred to as "Healthcare Providers") to furnish optometric care and services, including but not limited to, diagnostic tests, examinations, and other medical and/or surgical procedures, which is deemed necessary in the course of my care.

Acknowledgement of Receipt of Privacy Practices: I acknowledge that I received a copy of the Notice of Privacy Practices
Name
First Last
Signature
Date
MM slash DD slash YYYY
Patient or Parent/Guardian

Step 1 of 2

EMERGENCY CONTACT INFORMATION

PHYSICIAN INFORMATION