Authorization Information
Insurance and Financial Responsibility
By signing this form, I acknowledge and agree that:
- I am responsible for notifying the practice before my appointment of all my insurance information and plans.
- I am responsible for all charges not covered by my insurance plan.
- Once glasses are ordered, any insurance benefits not presented at the time of order cannot be applied retroactively.
- Based on the doctor’s findings and/or the nature of the visit and available coverage, either my vision plan or medical insurance will be billed accordingly.
- As part of the practice’s standard of care for a comprehensive eye examination, a digital photograph of the inside of my eyes will be taken to evaluate and document the health of my eyes. This imaging may help the doctor examine areas inside the eye and, when clinically appropriate, may reduce the need for dilation. I understand that my out-of-pocket cost for this imaging may range from $0 to $39 for both eyes, depending on my insurance plan and coverage.
EYEWEAR RETURN / EXCHANGE
If you are not completely happy with your purchase within the first 14 days, just let us know. We will do everything possible to make it right. We always strive to a 100% satisfaction guaranteed.
If we are unable to make you satisfied, we will be pleased to arrange an exchange. Given the custom nature of our products there are no refunds. A merchandise credit can be issued for a return (see associate for details). We do not exchange items which show signs of wear.
EYEWEAR ORDER CANCELLATIONS
Our lenses are made-to-order custom lenses. As such, once an order is placed, it cannot be cancelled or refunded. A merchandise credit can be issued.