Financial Policy

We are dedicated to providing our patients with the best possible care and service so it is important to us that you have a clear understanding of our financial policy. If you have any questions, please feel free to discuss them with our staff.

Please note: While our staff does their best to verify insurance coverage, it is ultimately your responsibility to understand your coverage, co-pays and deductibles. You are responsible for all charges you incur.

Personal Payment

Patients who are not covered by an insurance plan are responsible for their charges at the time of service. Payment
schedules may be arranged prior to treatment.

Minor Patients

A parent or legal guardian must be present for all patients under the age of 18, unless arranged with us prior to service. The adult accompanying the patient is responsible for payment for all services rendered.

Insurance/Third Party

We will bill up to two insurance companies on your behalf. Estimated co-pays are due at the time of service. Once insurance payment is received, you will be billed for any unpaid portion that has not been
covered by your policy. (Rule excludes of-network for medical coverage, we worker's comp claims.)

Medical Insurance

Our doctors are legally and ethically required to address signs of ocular disease. Vision benefits do not cover any testing related to disease. If you do not have medical insurance or if we find you are out-of-network for medical coverage, we certainly do our best to provide estimation of fees or referral to in-network doctors when indicated.

Additional Information


  • There will be an additional charge of $35 for all invalid or returned checks.
  • Any account that has not arranged a payment plan or has late or outstanding charges may be turned over to collections after 60 days. In this event, the patient is responsible for a late fee of $40.
  • Any charges or credits below $3.00 will be left on account until the next visit.

Signature of responsible party :


Date: