1. Payment for professional services are due the day the services are provided.
2. Payment for eyeglasses and/or contact lenses is due before the materials are ordered. For your convenience, we accept cash, checks, debit cards and all major credit cards.
3. We are providers on many insurance plans and will happily file those claims on your behalf. Payments for co-pays, deductibles and items known not to be covered by your insurance is expected at the time of your visit. You are also ultimately responsible for all charges for which your insurance company denies payment when we receive your Explanation of Benefits statement from them. We ask patients with insurance for which we are not providers to make payment in full when services are rendered If applicable, an itemized statement will be given to you at the time of your visit so you can submit it to your insurance company.
4. Both Established and New Contact Lens Wearers are subject to an Evaluation/Fitting Fee. This fee varies by the complexity of the individual's prescription and is separate from the exam co-pays. This is a global fee that covers multiple visits until the prescription is finalized and is due at each annual eye exam. These fees are due at the date of the service.
5. For those with Flex Spending Accounts, payment in full for services rendered and materials ordered is expected. An itemized statement that can be submitted to your insurance company for reimbursement will be given to you at the time of your visit.
6. If payment from your insurance company has not been received in 60 days, you will be responsible for paying your account balance in full.
7. Finance charge of $10 will be applied to accounts after 60 days.
8. In some families there is an arrangement between parents as to who is the responsible party. This is strictly between the parents and we require that the parent who requests evaluation and treatment for the child and attends the appointment is the one who will incur the fees.
9. A service charge of $30 will be applicable for all checks returned for any reason.
10. If legal action is required to collect any unpaid charges, you will be billed the cost of attorney fees, court costs and collection fees in addition to any unpaid balances.
11. All purchases of materials are final and non-refundable. Every effort will be made to ensure you are delighted with your purchases.
I acknowledge that I am responsible to pay for all charges associated with the services and materials provided by Chili Vision Group.
I understand that if I fail to make my payments, my account may be turned over to a collection agency. (Please enter name in the box below)