Patient Agreement

I realize that I am financially responsible for all services rendered to me by Washington Eye Doctors (the Practice).

All professional fees are due when service is rendered.

All eyewear and contact lenses must be paid for in full when ordered.

There is a $15.00 fee for all returned checks.

A collection fee equal to 35% of the balance due will be added to all accounts referred for collection services.

The practice reserves the right to charge for canceled or missed appointments with less than 24 hours notice.

INSURANCE AUTHORIZATION AGREEMENT

I, the undersigned, realize that I am financially responsible for all services rendered to me by Washington Eye Doctors, PC (the Practice).

For those insurances for which the Practice accepts assignment, I realize that I am personally responsible for all co-payments, deductibles and non-covered services, as dictated by my insurance coverage.

Patients with Vision Coverage for Eye Examinations

You will be receiving a comprehensive exam today. The doctor will examine you for medical eye conditions including glaucoma, cataracts, and diabetic eye disease. You will also have a refraction to determine if prescription lenses are needed or if there are changes in your prescription. If your eyes are determined to be healthy and require no care other than corrective lenses, a basic wellness eye exam fee will be charged. We will be happy to bill your Vision plan, if we are on your plan, or otherwise assist you in filing your insurance.

However, if your exam reveals a medical eye condition, you will be charged an office visit plus a fee for the refraction. In this case, the office visit may be filed with your Health Insurance. Your out-of-pocket expenses may be only for your co-pay and any unmet deductible, plus the refraction, which we can bill to your Vision Plan, if permitted. Again, we will be happy to bill your Health Insurance if we are on your plan, or otherwise assist you in filling your insurance.

Some medical conditions may require immediate attention which will necessitate a return visit for your comprehensive exam.

Patients Wearing Contact Lenses

Contact lens fitting and service fees are always additional to the examination fee. We will bill the Vision Plan for contact lens services and materials when applicable. You will be responsible for all contact lens services and materials above your Vision Plan coverage.

Authorization

I, the undersigned, hereby authorize Washington Eye Doctors, PC to apply for benefits for covered services rendered by the Practice, and request that the payments from Medicare Part B, Vision Service Plan and/or my insurance carrier be paid directly to the Practice. I agree to all of the above statements regarding my Vision Plan and its limitations. I certify that the information that I have reported with regard to my insurance coverage is correct and further authorize the release of any necessary information, including medical information for this or any related claim, to my insurance carrier(s) (or in the case of Medicare Part B benefits, to the Social Security Administration and Health Care Financing Administration). I permit a copy of this authorization to be used in place of the original.