Thank you for choosing Eye See Clear Vision as your Eye Care Provider. We are committed to the success of your treatment. Payment of your bill is part of your treatment arrangement.
FULL PAYMENT IS DUE AT THE TIME OF SERVICE – No Refund Policy
WE ACCEPT CASH, CHECKS, AND ALL MAJOR CREDIT CARDS.
Statement of Financial Responsibility – I understand that I am responsible for the payment of this account, and hereby assume and guarantee prompt payment of all the expenses incurred. This includes Medical Services Rendered, Contact Lenses and Fashion Frames arid Fashion Frame Lenses or other products not be covered by my insurance carrier, therefore I will become fully responsible for payment for any of these services.
For patients with “Out-of-Network” coverage – I Waive the Usual, Customary and Reasonable Clause. I acknowledge that the fee charged by Eye See Clear Vision for services rendered to me, may exceed the fee considered “usual, customary and reasonable”, due to specialized services. I agree to pay Eye See Clear Vision fees in full.
No Show Missed Appointments – Upon making your appointment you acknowledge that if you cancel with less than 24 hours advance notice, our policy is to charge $50.00 for a missed appointment.
Procedures – We will ask that you pay 100% of any outstanding deductible/co-insurance prior to your procedures. Contact, Lenses, Fashion Frames and Fashion Frame Lenses Have a No Return or Cancellation Policy.
Financial Agreement – The undersigned agrees whether he/she signs as agent or as patient, that in consideration of the service to be rendered to the patient, he/she obligates himself/herself to pay the account with Eye Clear See Vision in accordance with the regular rates and terms of Eye Clear See Vision. Should the account b: referred to an outside agency or an attorney for collections, the undersigned agrees to pay reasonable collection and attorney fees for collection expenses.
30-Day NO ADAPT POLICY FOR ALL INSURANCE CONTACT LENSES AND/OR FASHION FRAMES. This means if you cannot see don’t wait more than 30 days to inform us, or you will have to pay for the change.
I acknowledge that all Sales are Final. There is a NO Return Policy or Cancellation Policy on Contact Lenses or Fashion Frames and Fashion Frames with Lenses after the product is ordered.
