Please read our policy and fill out the form at the bottom to receive $5 off.

Our goal is to provide you with the best eye health care and the most positive experience. We also want to establish and maintain a pleasant professional working relationship with you. Thus, please take a few moments to review the following information.

• Payment is expected at the time services are rendered.
• Payment Options: Cash, check, debit or credit card (MC, VISA, DISCOVER or AMERICAN EXPRESS).


• Our fees are considered usual and customary for this area. They are not set by an “insurance company’s view of usual and customary”.


• In a divorce situation, the adult bringing the child is responsible for payment at the time services are rendered.

Vision Insurance: The ultimate financial relationship is between our office and you. NOT our office and your insurance company. If you have vision insurance, we will bill your company directly as a courtesy to you. To do this correctly and promptly, we need the most current and accurate information, including verification of insurance and proper identity. Your understanding during this process is appreciated.

Medical Insurance: If our doctors deem necessary that your exam is a medical exam, we will then bill your medical insurance directly as a courtesy to you also. Once again our financial relationship is between our office and you. Any and all co-pays, coinsurance or deductibles are due at time of service.

At your visit to our office, our staff will contact your insurance company to determine as best as possible: effective dates, benefits, deductibles, yearly maximums and co-pay percentages and any other important information which will allow you to receive the maximum allowed benefit. We then estimate any costs not covered by your insurance and expect these costs to be paid at the time of service. We cannot guarantee payment of benefits by your insurance company as initially reported to us. Therefore, we will send you a statement for any additional costs after the processing of a claim from the carried

Once the carrier is billed for services rendered, we will allow 60 days to receive payment. If no payment is received after 60 days, the insurance balance will become you responsibility.

Missed Appointment Fee: Patients who do not show up for an appointment or cancel with less than a 24 hour notice will be charged a $25 fee. This fee must be paid before a new appointment is scheduled. Patients with three missed appointments will be asked to transfer their records to another doctor.

Parent Responsibilities:

• Payment of all fees, including deductibles, co-pays, and any services not covered by your insurance at time of service.


• Any balances resulting from insurance company rejections or underpayments.


• $30.00 charge when a check is returned from the bank as “NSF”


• Any additional fees incurred by us when an overdue accounts is referred to the American Credit Bureau.

Finance Charge: A finance charge will be imposed on each item of your account which has not been paid within thirty (30) days of the time the item was added to the account. The FINANCE CHARGE will be computed at the rate of one percent (1%) per month or an ANNUAL PERCENTAGE RATE of twelve (12%) percent. The minimum Finance Charge is $.50.

If your account becomes past due, we will take all necessary steps to collect this debt. If we have to refer your account to a collection agency or a lawyer you agree to pay all the collection fees, lawyer fees and court costs that are incurred. In case of suit, you agree the venue shall be in Greenup, Kentucky and Greenup County.

I have read and agree to follow the policies and my responsibilities as outlined above.

**Scanned Copy Serves as an Original**