Form revised 03/2022
Our goal is to provide the best, personalized, professional eye care for you and your family. We provide:
- Routine eye examinations
- Medically related eye care
- Contact lens examinations
- Vision therapy & Brain Injury evaluations
Routine Eye Examinations and Vision Care Plans:
A routine eye examination is for the following: near-
sightedness, far-sightedness, astigmatism, presbyopia (difficulty seeing at near due to increasing age), eye glasses
and contact lenses. Vision Advancement Center, PLLC is NOT contracted
with any vision plans. However, we are an open access provider and will work with you to use your vision
insurance benefits for reimbursement by your vision plan. Payment in full is expected on the day of services. A
routine eye examination does not cover the diagnosis, management, and/or treatment of medically related eye
Our office is committed to providing the best treatment to our patients. Our fees are representative of the
usual and customary charges for the level of service provided, materials prescribed, as well as the level of
advanced technology used to provide our patients with the most modern eye care in our area.
Please be aware that some, and perhaps all, of the services you receive may be
uncovered or not considered reasonable or necessary by Medicare or major medical and vision insurers. These
services may be required to be paid in full at the time of your visit or after we receive your explanation of
Medicare and most other medical insurance plans no longer pay for refractions. The refraction is the
test that is performed during your office visit to determine your best possible prescription (“which is better, one or
two?”). A refraction is also required to determine the health of your eyes. You will be asked to pay for the
refraction at the end of your visit. The fee for this test is $75.00.
Consent to Treat:
I request and give consent to Vision Advancement Center, PLLC and Advanced Vision
Therapy, PLLC to provide and perform such medical and vision eye care, tests, procedures, medications, and
other services and supplies as are considered medically necessary or beneficial for my eye and vision health.
Payment: You are responsible for any co pays, co-insurance, deductible, and other non-covered services.
Any surcharges for spectacle upgrades set by your vision insurance must be paid at the time of service
before any orders will be processed. If you are a self pay patient and/or your insurance cannot be verified
prior to your appointment, you will be required to pay in full the day services are rendered.
We accept cash,
personal checks, all major credit cards, and Care Credit. If you are being seen for any ongoing medical problems,
co-pays are due at each and every visit. If you foresee any payment problems, please speak to our office staff
prior to your appointment.
As a courtesy to our patients, we will file medical claims with medical insurance companies for
which we are providers. We will do our best to accurately verify benefits for services and/or materials, however, benefits quoted by your insurance carrier are not a guarantee of payment. Should your insurance deny a
claim for any reason, you will be responsible for any remaining balances as directed by your insurance.
Patients that receive a statement from our office are expected to remit full payment upon receipt unless previous
payment arrangements were made with our billing office. If you account must be referred to an outside collection
agency for non-payment, a fee will be added to your account to cover the expense incurred form the agency.
Patients in collections must make payment arrangements prior to scheduling another appointment with our office. If you receive a billing statement that you do not understand, please contact our office.
Proof of Insurance:
We are required by law to get an up-to-date copy of your insurance card(s) before you see
the eye doctor. If you do not present this at the time of your visit or fail to provide us with the correct insurance
information, you will be responsible for the balance of the claim.
If you have secondary medical insurance, it is your responsibility to have them set up to
crossover to each other. Any balance that does not automatically crossover to your secondary insurance will be
your responsibility. We will provide you with an itemized receipt that you can send with a copy of your
explanation of benefits that you received form your primary insurance for possible reimbursement.
If we do not receive payment from your insurance company within 60 days, the balance will
automatically be billed to you. If your account is over 90 days past due, you will receive a letter stating that you
have 21 days to pay your account in full. Partial payments will not be accepted unless previously discussed.
Please be aware that if a balance remains unpaid, we may refer your account to a collection agency. If this is to
occur, you will be notified by regular and certified mail that you have 30 days to find alternative eye care. During
that 30 day period, our office will only be able to treat you on an emergency basis.
Once your appointment has been confirmed it will be reserved for you to meet your eye
care needs. Please be courteous to our staff and fellow patients by keeping your confirmed appointment. If you are
unable to keep your scheduled appointment, please inform us as soon as possible. We do require a 24 hour notice
of cancellation of your scheduled appointment. A minimum fee of $50.00 may be charged to your account for
broken appointments based on the amount of time and service reserved for you. If you do not cancel 24 hours in
advance or no-show for your scheduled appointment 3 times in a 12 month period, we have the right to dismiss
you from our care.
I authorized Vision Advancement Center, PLLC and Advanced Vision Therapy, PLLC to act as my agent in
applying for insurance and/or Medicare benefits, and I authorize payment of these benefits directly to Vision
Advancement Center, PLLC and Advanced Vision Therapy, PLLC on my behalf. I authorize any holder of
medical information about me to release information needed to determine benefits payable for related services. If
I have additional insurance, my signature authorized release of the above medical information to any insurer or
agency I have given, and authorize my doctor to act as my agent above.
Patient or Responsible Party