Eligibility for medical insurance and/or routine vision benefits.
We always attempt to verify your plan eligibility for services and or materials before your appointment. Verification of eligibility is done as a courtesy only and is not a guarantee of payment. Please check with your plan administrator if you have any questions regarding your eligibility. Professional Vision does not participate in all insurance plans.
Liability
I understand that account balances and co-payments are due at the time of service. If I have medical insurance or routine benefits, I authorize my plan carrier to pay Professional Vision of Ellicott City directly. I authorize Professional Vision of Ellicott City to release any information required for payment to be made. If my plan carrier does not pay, or partially pays, I understand that I am responsible for payment in full for the remaining balance. My signature below verifies that I understand the above financial disclaimers.
If you are a contact wearer:
Contact Patient require additional diagnostic services with every exam, which are NOT included in the annual eye health evaluation. These fees are the responsibility of you, the patient, when you are pursuing contact lenses as an option for vision correction, even if you decided not to wear contacts in the end. You acknowledge that you are responsible for the costs of contact lens diagnostic services today (in addition to your other routine exam costs). Fees for contact lens evaluation services range from $85 to $200. Some Vision insurance plans provide small adjustments to those fees.
