Patient Financial Responsibility Agreement

Thank you for entrusting the health of your eyes to Village Eyecare. We are committed to providing comprehensive and high-quality services. To ensure a clear understanding of your financial responsibilities, please review the following information.

1. Insurance Coverage

Verification of Benefits: We will make reasonable attempts to file claims when we participate with your insurance plans. You are responsible for providing accurate insurance policy and subscriber information.

Co-Payments, Deductibles, and Non-Covered Services: You are responsible for copayments, deductibles, coinsurance, non-covered services or materials, denied claims, and any remaining balance. If a claim is denied, you are responsible for the retail cost of the services and/or products.

Medical Insurance: We are not on HMO panels. If your medical insurance does not cover services rendered or required medical testing, you are responsible for applicable charges, including self-pay pricing.

2. Payment Responsibility

Self-Pay Patients: Payment is due in full at the time of service. Accepted payment methods include cash, credit/debit cards, Klarna, and HSA/FSA cards.
Payment Plans: If you need financial assistance, please ask the front desk about available payment plans.

3. Cancellation Policy

Cancellation Fees: Please provide at least 24 hours’ notice to cancel or reschedule. Failure to do so may result in a $50 no-show/cancellation fee that must be paid before further services can be rendered.

4. Financial Responsibility and Collections

Outstanding Balances: After insurance processes your claim, any remaining balance is your responsibility. Unpaid balances may be referred to an outside collection agency. In case of default, you agree to pay applicable legal interest, collection costs, and reasonable attorney fees.

5. Authorization and Consent

By signing, you authorize Village Eyecare to bill your medical insurance and vision plan directly and receive payment for services rendered. You acknowledge responsibility for charges not covered by your insurance company or vision plan.

Patient Acknowledgment and Agreement

I have read and understand the financial policies of Village Eyecare. I authorize my eye care provider’s office to bill my in-network medical insurance for eye health evaluations and related services, and to bill my vision plan(s) for routine vision testing, eyewear, contact lenses, and other vision-related services and materials. I understand that verification of eligibility or benefits is not a guarantee of coverage or payment. I accept full financial responsibility for all copayments, deductibles, coinsurance, non-covered services or materials, denied claims, and any remaining balance not paid by my in-network medical insurance or vision plan(s).

Patient/Guardian Signature: ____________________________________

Date: ________________________________________________________

Thank you for choosing Village Eyecare! We look forward to providing you exceptional care.