Financial Responsibility

Please read and initial our Office Policies below:

Financial Policies and Assignment of Benefits

Payments are due at time of service. For our patients with insurance, our contracts with insurance companies require us to collect your co-pay at the time of service. Payment is also due at time of service for any portion of your visit not covered by your insurance. We accept cash, check, and Visa/Mastercard. If your personal check is returned due to non-sufficient funds, a returned check fee of $25.00 will be charged to your account.

Glasses prescriptions are guaranteed for 90 days from the date of exam. Any changes to the prescription occurring after the 90 days from the date of exam will incur an office visit fee.

Contact lens follow-up care will be charged as an office visit if beyond 90 days of exam or after a contact lens prescription has been dispensed. Contact lens care beyond six months from the date of exam will incur a new exam fee. First time contact lens wearers are required to be trained in office prior to release of contacts. Each hour of training is $25.00.

As a courtesy to our patients, we will file your insurance claim after each visit. If your insurance company has not paid your claim within 90 days, you will be required to pay in full. Our office does not enter into disputes with insurance companies over coverage. It is your responsibility to resolve any disputes over payments by your insurance.

Should a billing statement be sent to you, you will have 30 days to pay any outstanding balance. Thereafter, late payment charges of $8.00 per month will be added to your account. In the event your account is forwarded to collections, you agree to reimburse our office the fees of any collection agency and all costs and expenses, including reasonable attorneys’ fees, we incur in such collection efforts.

Many patients have both medical and vision benefits. Vision Plans are designed to cover a prescription for glasses and help pay for lenses. It is not intended to cover medical conditions and treatments. Medical insurance applies to situations when a medical problem affects the eyes (such as diabetes, cataracts, and glaucoma, to name a few). When such conditions are being managed, vision plans do not cover these issues. We are obligated to comply with the regulations set forth by insurance companies.

If we are not on your insurance company’s panel, we can provide you, upon your request, with an itemized receipt so that you may file a claim with your insurance company for reimbursement. The amount of reimbursement depends on your vision plan coverage.

I hereby authorize GoTo Optical Eyewear + Eyecare to: (1) release any information necessary to insurance carriers regarding my illness and treatment; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature or digital signature to be used in processing claims for the period of a lifetime. This order will remain in effect until revoked by me in writing. I have requested medical services from GoTo Optical Eyewear + Eyecare on behalf of myself and/or dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of treatment authorized. I further understand that fees are due and payable on the date services are rendered and agree to pay all such charges incurred in full upon presentation of statement.