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Financial Policy Form

  • Premier Eye Center Contact lens Policy:

    Both Established and New contact lens wearers are subject to an Evaluation/Fitting fee. The fee varies by the complexity of the individual’s prescription and is separate from the exam co-pays. This is a global fee that may cover multiple visits until the prescription is finalized and is due at each annual eye exam. These fees are due at the date of service.

    Vision and Medical benefits:

    • There are two types of health insurance that will help pay for your eye care services and optical products. You may have both types and Premier Eye Center accepts most insurance plans in both categories: 1) Vision plans (such as VSP, EyeMed, and others) and 2) Medical insurance (such as Blue Cross/Blue Shield, Medicare, and others).
      • Vision plans only cover routine vision wellness exams, along with additional coverage toward eyeglasses and contact lenses. Vision plans do not cover medical eye examinations (the diagnosis, management, or treatment of eye health problems).
      • Medical insurance must be used for medical eye care. At Premier Eye Center we perform medical eye examinations by diagnosing, treating, and managing ocular health conditions such as dry eye, cataracts, glaucoma, blepharitis, and many more. We also utilize diagnostic testing in order to perform a comprehensive exam which is billed to your medical insurance plan.
      • If you have both types of insurance plans, it may be necessary for us to bill some services to one plan and some services to the other. We will follow a procedure called “coordination of benefits” to do this properly and to minimize your out-of-pocket expense.
      • After billing your medical or vision insurance, if there are charges that are not paid by your insurance, such as deductibles, co-pays, or non-covered services as allowed by the insurance contract, we will bill you directly.
      • If you have an HRA/HSA account, it is your responsibility to understand that any medical care that is done in the office may be paid through this account, since your insurance company dictates this based on the contract you have with them.
      • If you are utilizing your vision plan for services or materials, Premier Eye Center holds the right to decide the most appropriate manner to bill services and materials. At Premier Eye Center we only fit premium contacts and ophthalmic lenses, and oftentimes these are not under insurance formularies. Please be aware that if ordered and billed through your vision insurance, the following may occur:
    • Your materials may not be ready for 2-4 weeks depending on the labs that will have to be used due to insurance.
    • Your insurance company is just that, an insurance company, and not an authorized dealer for materials. Therefore, products such as lenses or contacts may come from vendors that we do not participate with so we can only coordinate the materials arrival to you.
    • Since the materials are generated and produced from your vision insurance company, if anything were to arise such as a broken frame, ripped contact lens, prescription change, etc., we, unfortunately, are not able to replace or provide warranties for products rendered from your vision insurance company.

    Financial Responsibly Acknowledgment

    I acknowledged I have insurance and assign directly to Premier Eye Center all medical and/or vision plan benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits.

    1. Payment for professional services (eye examinations, specialty testing, office visits) is due the day services are provided. Payment for eyeglasses and contact lenses is due in full the day materials are ordered. All sales are rendered final at the time of purchase and no refunds will be allowed. Exchanges for eyewear or contact lenses maybe honored as needed. Due to optical orders being custom, if a refund is honored a 30% restocking fee will apply. For your convenience, we accept cash, checks, and credit cards-Visa, MasterCard, American Express and debit cards. We also provide Care Credit authorizations.
    2. We are providers for a wide array of insurance plans and are happy to file those claims on your behalf. Payments for copayments, deductibles, and items known not to be covered by your insurance are expected at the time of your visit. You are also ultimately responsible for all charges for which your insurance company denies payment when we receive your Explanation of Benefits statement from them. Premier Eye Center will verify your insurance with the information you provide, if the insurance company gives the incorrect information, ultimately you are responsible for all charges. We ask patients with insurance for which we are not providers to make payment in full when services are rendered. If applicable, an itemized statement that can be submitted to your insurance company for reimbursement will be given to you at the time of your visit. 
    3. For those with flex spending accounts, payment in full for services rendered and materials ordered is expected. An itemized statement that can be submitted to your insurance company for reimbursement, will be given to you at the time of your visit.
    4. If payment from insurance company has not been received in 60 days, you will be responsible for paying your account balance in full.
    5. Finance charges at the rate of 1.5% / month (18% APR) will accrue on all outstanding balances over 90 days.
    6. In some families, the question of who is responsible for a child's bill is uncertain. Since we are not privy to any separation agreement or court order, this is strictly a matter between parents. We must insist, therefore, that the parent who requests evaluation and treatment for the child will be responsible for all fees incurred.
    7. A service charge of $30.00 will be applicable for all checks returned for any reason, including insufficient funds and stop payments. For any amount over $300.00 a service charge of 10% will be charged.
    8. Payment plans can be requested. Premier Eye Center will continue to assist the patient in setting up this payment plan. Patients must leave a valid credit card on file in which the patient will agree to be charged a set amount (determined at that time) until balance is paid.
    9. If a balance is not collected by the final notice, the office will send your account to collections and you will be charged $150 charge on top of the balance owed, if balance is not paid in full before that time.
    10. If our office is required to take legal action to collect any unpaid charges, you will be billed the cost of attorney fees, court costs and collection fees in addition to any unpaid balance.

    Premier Eye Center employs a No show/ Cancellation policy

    • After 2 no shows, credit card information will be stored in our system. If a patient does not call or show after education of this policy, a $35 no show fee will be applied to their card on file, per person that missed.
    • A family of 3 or more who would like to schedule a block of appointments on any given day, will be required to furnish credit card information to confirm the appointment block. The $25 fee per person will be applied if the patients do not show or there is no communication to cancelling at least 24 hours prior to examination.
    • Patients requesting Saturday appointments are required to leave credit card on file in order to reserve the appointment time they desire.
    • Patients are allowed to cancel no less than 24 hours before their designated time.
  • I acknowledge all policies stated above for Premier Eye Center and accept all policies by signing below
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