Financial Policy

If you have filled out the New Patient Form, please continue and fill out this Financial Policy form.
Please read all of this information.
Your submission is your acknowledgement that you have read and agree to the following:


Our goal is to provide your eyecare at the least cost to you. In order to minimize any confusion, we ask that you review the following policies:

  1. You are ultimately responsible for payment of charges for services you receive from our office. It is your responsibility to understand the rules and terms of your insurance. We may be listed as a member of your insurance plan but that does not guarantee your insurance will cover the services you receive from us. Some eye examinations are considered routine because the patient does not have any medical eye issues. Many insurance plans do not cover routine eye examinations. If your examination is deemed to be routine in nature not involving medical problems, you will be responsible for the entire charge for the examination and not just a co-pay. We have no way of knowing the situation with your eye health until we do your examination so we will be unable to tell you in advance if your exam will be covered. Generally, problems such as eye pain, redness, sudden vision loss etc. are likely to have a medical reason.
  2. All co-payments and deductibles are due at the time of service. You may be asked to reschedule your appointment if you have not made prior payment arrangements. Most insurances including Medicare do not cover the refraction (the part of the examination to test your vision for glasses). Therefore, the refraction fee of $45 is your responsibility in addition to co-payments or deductibles
  3. It is your responsibility to provide us with your current address, telephone number, email address and insurance information at each visit.
  4. If you are experiencing personal circumstances that will make payment of our charges difficult for you, please contact us in advance of your appointment.
  5. If you are unable to keep your scheduled appointment and do not call us to cancel or reschedule the appointment, there may be a $35 charge. We must receive notification of this change no later than 24 hours from the scheduled appointment.



The REFRACTION is the part of an eye examination when we determine if you need a new prescription for eyeglasses. Without the refraction, we cannot provide a prescription for eyeglasses.

Historically, most insurance plans do not pay for this portion of an examination. If your plan does not pay for glasses or contact lenses, they most likely will not pay for the refraction. We do not include this procedure in our routine examination charge.

You may elect not to have the refraction done in this office, however we will not be able to provide a prescription for glasses without it.

If you do have a refraction done in our office, there will be a $46.00 charge at the time of service, in addition to any co-payment or other non-covered fees. We will provide you with a receipt that you may file with your insurance company for reimbursement if your insurance plan considers this a covered expense.

We do not understand why most insurances do not pay for refractions. We appreciate your understanding in this matter. Refraction is a very important part of an examination if you require corrective lenses. We truly wish that all insurance plans considered this a covered expense.

Notice of Privacy Practices Acknowledgment Patient Acknowledgment Form

Our notice of Privacy Practices provides information about how we may use and disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change.

You have the right to request that we restrict how protected health insurance about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this consent in writing, except where we have already made disclosures in reliance on your prior consent.

  • Row 1 NEW