FINANCIAL AGREEMENT

Welcome, and thank you for choosing Austin Eye Studio! We are committed to providing you with quality, personalized eye care and the best possible service. Understanding your financial responsibility is an essential part of your care. Please review the following policies carefully. By signing below, you acknowledge that you have read and agree to the terms outlined. If you have any questions, our team is happy to assist.

Insurance Claims / Non-Covered Charges

It is your responsibility to know your insurance coverage, including eligibility, deductibles, copays, exclusions, and referral requirements. If Austin Eye Studio is in-network with your plan, we will bill your insurance as a courtesy. However, if coverage cannot be verified or services are not covered (including contact lens fittings, refractions, or advanced diagnostic testing), you agree to pay in full. You are responsible for any remaining balance not paid by your plan. Verification of benefits is not a guarantee of payment. If payment is not received within 60 days of claim filing, the balance becomes your responsibility.

Authorization & Financial Responsibility

You authorize Austin Eye Studio to release any medical or billing information necessary to process claims and allow direct payment of insurance benefits to our office. You agree to be financially responsible for all services provided, including those not covered by insurance.

Pre-Authorization & Financial Responsibility

If your insurance requires a referral, it is your responsibility to obtain one from your primary care provider prior to your visit. Without a valid referral, you may be asked to reschedule or pay out-of-pocket.

Medicare Patients

Austin Eye Studio is a participating Medicare provider. Medicare patients are responsible for copays, deductibles, and any non-covered services, such as refractions. If services are not covered by Medicare, you may be asked to sign an Advance Beneficiary Notice (ABN) and pay directly.

Patients Without Insurance / Out-of-Network Plans

If you do not have insurance or choose to use an out-of-network plan, full payment is required at the time of serive. 

Returned Checks

Returned checks are subject to a $25 fee. The balance must be resolved immediately. We accept all major credit cards and HSA/FSA cards.

Eyewear / Contact Lens Products

All optical purchases (eyeglasses, contact lenses, etc are custom-ordered and non- refundable. If a product is defective, we will gladly work with the manufacturer to find a solution.

Missed Appointment / No-Show Policy

We kindly request at least 24 hours' notice to cancel or reschedule appointments. A $35 fee may apply for missed appointments, and $100 for repeated no-shows. These fees are not billable to insurance. 

I acknowledge that I have read, understand, and agree to the Austin Eye Studio Financial Policy.