Patient Financial Responsibility Agreement

ln order for Vision Check Optical to continue providing our patients with quality medical care, we must receive the contracted payment for our services. Ensuring that we are appropriately and promptly paid is the PATIENT'S RESPONSIBILITY.

As a part of Vision Check Optical, LLC I understand:

I must provide a copy of my most recent insurance card and a picture ID.

Vision Check may reschedule my appointment if insurance cannot be verified prior to my appointment.

I must cover non-covered insurance charges, including my co-pay, co- insurance, insurance deductible, out-of-network charge differential; and all other non-covered charges at the time of service, or when otherwise advised as per my insurance contract.

There will be a $25.00 fee for patients who fail to show for a scheduled office appointment and do not provide 24 hours notice of cancellation of appointment.

Print name: _____________________________

Signature: _________________________________

Date: ___________

Office Personnel (received by and date): _______________________________

In order to provide you with the best ocular health, please contact our office if you are having financial difficulty so that we may work with you to meet your needs.

HIPPA Privacy Act

Privacy Policy Acknowledgement Statement I hereby acknowledge that I have been made aware that Vision Check LLC has a privacy policy as stipulated by the Health lnsurance Portability and Accountability Act of 1996.

As a patient of Vision Check LLC, I understand and acknowledge the following:

Vision Check has a privacy policy in effect.
Vision Check LLC has made this policy available for review at by providing the aforementioned at my request.
Vision Check has made me aware that I may receive a copy of the privacy policy at my request.

Upon review of the above statements, please sign at the bottom to acknowledge that you have been made aware of our policy and have read and understand this acknowledgement form. If you would like a copy of our privacy policy, you may request one at any time.

____ NO, I do not want a copy at this time.

____ Yes, I would like a copy of your HIPAA policy.

Print: ___________________________

Signature:________________________

Date: __________________

Office Policies and Procedures

Vision Check LLC reserves the right to:

Refuse services to any one
Enjoy a profanity free workspace
Not issue refunds
Make everyone feel welcome and safe
Reschedule appointments if insurance is not pre-verified
Bill non-covered services
Follow the FDA recommendations for polycarbonate lenses to patients under 18 or with an underlying ocular condition.
Help the world see better!

If you any questions about our office policies, please ask for a member of management.

Revised Nov 2023