PATIENT INFORMED CONSENT OF POLICIES

PAYMENT IS DUE IN FULL AT TIME OF SERVICE

BENEFIT ASSIGNMENT:

The assignment of benefits of any insurance policy and/or healthcare reimbursement plan shall not be deemed a waiver of DuPage Optical’s right to require payment directly from undersigned, the patient or the guardian.

 

BILLING INFORMATION:

As a courtesy, DuPage Optical files claims directly to your medical insurance or vision plans (in most cases). It is your responsibility to verify your benefits and provider network coverage. If you have questions about your plan benefits, please contact your medical or vision plans directly. It is your responsibility to provide DuPage Optical with correct information including insurance, pre-certifications, responsible party, date of injury, type of accident, policy and/or group numbers, etc. Should the information change, it is your responsibility to update it within a timely manner. If you supply DuPage Optical with incorrect information, the balance of the account at the last date of service will be entirely patient responsibility. DuPage Optical will not be responsible for rebilling, appealing or other dealings with newly provided insurance company. If your balance becomes 90 days or more overdue, our office reserves the right to refuse appointments and we will send your account to a collection agency for collection. In the event that your account is sent for collection, you will be responsible for all cost and fees, including reasonable collection agency fees.

This policy is subject to change without notice.

METHODS OF PAYMENT:

DuPage Optical accepts cash, credit cards, debit cards, Care Credit and personal checks as methods of payment. There is a fee of $30.00 for any checks returned by your bank. Checks shall be written to DuPage Optical.

REFUND POLICY:

Custom Eyewear – No Refunds on Custom Eyewear.

Doctor Changes – Lenses will be remade up to 90 days from the date of the original receipt at no cost and at 50% of the original cost of lenses thereafter.

Contact Lens – No Refunds on Custom made lenses.

Boxed Lenses – Exchange for credit if unopened and unexpired.

 

Missed Appointment Fee:

DuPage Optical requires at least a 24 hour notice to cancel an appointment. You may be charged a Late Cancellation/No Show fee of $50.00. This fee is not billable or payable by insurance. Patients with more than three missed appointments will not be able to schedule appointments without a deposit of $50.00 to be applied at newly scheduled appointment. We understand that emergencies do occur and will attempt to make reasonable accommodations for that. If the appointment can be made up within the week of the missed appointment, the $50.00 fee will be waived.

Waiver of Confidentiality:

You understand if this account is submitted to an attorney or collection agency or if you’re past due status is reported to a credit reporting agency, the fact that you received treatment at our office may become a matter of public record.

I have been informed of my financial responsibility and agree to the terms and conditions as stated on this form. I understand that my health insurance policy is a contractual agreement between my insurance carrier and me. It is therefore MY RESPONSIBILITY to question my insurance company regarding delays in payment and/or denial of coverage, incorrect processing of claims by the insurance company, as well as any requirements that may be included in my insurance policy coverage (i.e. Pre-certifications, in-network status, referrals, co-insurances, and deductibles).

Authorization for Release of Information to Family Members

Many of our patients allow family members such as their spouse, parents or others to call and request medical or billing information. Under the requirements of HIPAA we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members indicated below. DuPage Optical to release my medical and/or billing information to the following individual(s):

Patient Information I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to re-disclosure by the above recipient. You have the right to revoke this consent in writing.