Renton Vision Clinic Financial Policy Patient Name: _____________________________________________ Date of Birth: _____________________________________________ Welcome to our office. In order to better serve you; we at Renton Vision Clinic check eligibility and benefits with your insurance company before any services are provided. To avoid any misunderstandings, we suggest that you discuss your concerns with our staff and review this information carefully.

Insurance Billings To bill your insurance correctly we will need you to provide the following before you are seen:    

Current Insurance Cards (Medical and/or Vision). Current picture identification. Current patient information form completed. This financial form signed.

Most insurance policies pay only a portion of the total fees. If you have any further concerns of coverage we recommend you contact your insurance company directly. Our staff will help you with billing in any way we can; however, our office cannot be responsible for collecting or negotiating a disputed insurance claim. In most cases, regardless of your coverage, you are responsible for the entire account.

Contact lens exam and Glasses Policy Contact lens exams, fittings, and evaluations are generally NOT a covered benefit under MOST insurance plans. If you choose to be examined for contact lenses and/or need to be fitted with contacts you will be responsible for all incurred charges for professional services. Please also be aware that contact lenses and eyeglasses are ordered and fabricated custom to your prescription, and may not be cancelled or refunded once the order has been placed. You may choose to use a previously owned frame for a lens update. Although we always take great care in handling your product, it is not the liability of Renton Vision Clinic or its affiliated labs if a frame is broken, lost or stolen during the lens fabrication and mounting process. In signing below, I agree to be financially responsible for all charges. I understand that my insurance is not a substitute for payment and it is my responsibility to pay, in advance, the deductible, the co-pay and any other balance not paid by my insurance company. I also understand that verification of my benefits is not a guarantee of payment. I have had my insurance explained to me, I understand all policies discussed on this sheet and have had an opportunity to ask questions. All unpaid accounts over 60 days will receive an interest charge of 1.5% per month (or 18% per year).

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