WEEKLY PAYMENT PLAN

Program Details: Your program will begin on Type a label and conclude on  Type a label 

• Type a labelweeks of in-office vision training sessions, held once a week
• Each session lasts 45 minutes, starting at the top of the hour
• Comprehensive vision training materials and supplies will need to be rented or purchased
• Progress evaluations to monitor improvements:
• o 12 sessions of vision therapy prescribed:
  • 1 progress evaluation at around 10 weeks at no charge
• o 24 sessions of vision therapy prescribed:
  • 2 progress evaluations at around 10 and 22 weeks at no charge
• o Less than 12 sessions prescribed:
  • 1 progress evaluation at $95.00
• The fee for each Vision Training session is $158.00
• Monthly payments are based on a 4-week billing period and may vary depending on the number of sessions that fall within each billing period. Some months may include five sessions rather than four, and payment will be adjusted accordingly. The monthly payment plan ends during the month of the last scheduled session.

Your individualized Vision Training Program has been individually designed by your doctor, to address your specific needs and goals. As you progress, adjustments may be made to your program, including changes to the frequency or intensity of training, in order to best support your neurological and visual improvements.

We are dedicated to providing the highest standard of care and are here to assist you throughout this process. Should you have any questions or concerns, we encourage you to reach out to our office at any time.

By initialing below, you acknowledge and agree to the following terms:
InitialPayment Authorization: : I authorize automatic weekly billing of $158 to a valid credit card, which will be securely kept on file. I understand that my card will be charged each week on the day of my scheduled session regardless of attendance.
InitialCommitment to Weekly Sessions: I understand that weekly sessions are vital for skill development and that progress in vision therapy builds from one session to the next. Missing sessions may delay or hinder therapeutic progress. 
InitialMake-Up Sessions: If I am unable to attend a scheduled session, I may schedule a make-up session prior to the agreement’s end date, either virtually or at any of the three available locations. Make-up sessions can only be scheduled up to 2 weeks in advance.
InitialCancellation Policy: I understand that if I cancel or reschedule a session with less than 24 hours' notice, I will be charged a $35 cancellation fee.
InitialInsurance Notice: I understand that the Vision Development Team is an out-of-network provider for all insurance companies. If requested, I will be provided with claim forms and I am responsible for submitting them to my insurance provider.