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Crown Point Eye Care
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2018-11-01T18:30:41+00:00
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PHONE:
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ADDRESS:
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City
State / Province / Region
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Afghanistan
Albania
Algeria
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Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
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Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Whom may we thank for referring you to our office?:
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
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