Intake Form

Cancellation and No-Show Policy:
Exam slots are limited and valuable. To serve our patients better, we ask for proper notice for any cancellations. All patients are required to provide at least 24 hours advance notice when cancelling an appointment so that we may provide other patients with care. We understand that you may miss your appointment due to an emergency, for this reason we also reserve the right to asses each situation on a case by case basis. While we do provide reminders the day before the appointment it is the patient’s responsibility to remember the appointment. After three (3) missed appointments, the practice may at its discretion, choose to discontinue your care.

Late policy:
If you arrive more than 15 minutes late to your appointment you will be asked to reschedule your appointment, unless the doctor’s schedule can accommodate you.
Priority will be given to patients who arrive on time and you may have to be worked in between them.

Optical Policy:
Eyeglasses are custom order prescription medical devices, therefore, are non-refundable. Patients have 90 days to pick up orders unless an alternative agreement has been made.
Patients have 90 days after the prescription is filled to come in for a complimentary refraction if the prescription is not working. A one-time lens remake within the 90 days, is considered if we determine the prescription needs to be adjusted.
Although we always exercise the greatest of care, we are not responsible for the patient’s own frame should it break while we are adjusting, repairing, or reusing the medical device for a new prescription. This includes frames that are purchased elsewhere and brought to us and non-prescription glasses.

Contact Lens Fit:
A contact lens evaluation is a necessary and state regulated service in order to ensure the proper fit of a contact lens. The evaluation is an additional service to the comprehensive eye exam and has a separate fee that will cover the initial evaluation and all contact lens related follow-up visits for a period of 90 days from the original appointment.

Payment Policy:
Payment is required when services are rendered, or materials are ordered. Quotes of insurance coverage are based on information from the insurance company and are not guaranteed. Although we will gladly bill insurance for you, patients remain responsible for their charges even after insurance has been billed. If payment has not been received from insurance after 90 days, the patient will be expected to pay RidgeView Optometry. Patient's are responsible for payment of their account balances. If it becomes necessary to use a collection agency for any amount owed on this or subsequent visits, the patient agrees to pay for all costs and expenses including reasonable attorney’s fees. Accounts assigned to collections will be charged a 3% collection fee. Please contact our office to set up a payment plan if there is financial distress, we don't want to see this happen with any of our patients.

Self-pay Services:
Self-pay patients will receive our self-pay discounts tailored to each service. All charges must be paid in full at time of services rendered. If you have any questions or concerns regarding specific charges or discounts, please ask our staff members prior to receiving services to assure both parties are aware of what will need to be collected on the date of service.

Insurance:
As a practice we participate in most major insurance plans, including Medicare and Medicaid. It must be understood that if you are insured by a plan we are not in network with or we cannot verify coverage, payment in full will be expected at the time of your appointment. Knowing your insurance is your responsibility. Please contact your insurance company prior to your appointment with us to clarify your coverage/benefits. All co-payments must be paid at the time of service. This arrangement is part of your agreement with your insurance company. Failure on our part to collect co-payments, deductibles, and co-insurance from patients can be considered fraud. Please assist us in upholding the law by paying your insurance costs at each visit. Please be aware that if we do take your insurance, we still offer services that are not covered by any insurance company. If you decide to receive a non-covered service, it must be paid the same day, in full. We will not bill any of the non- covered services to your insurance company. These will be the patient’s responsibility entirely. If you have any questions or concerns regarding which services will not be covered by your insurance, please ask a staff member or your doctor prior to receiving care. We will be happy to provide clarification needed.
Release of Information:
I authorize RidgeView Optometry to disclose and release to my insurance carrier(s), including Medicare, Medicaid, Medigap/Supplemental benefits providers, and private insurers, as applicable, any medical and treatment information only needed for payment purposes for services rendered. I authorize use of this form for the release of information needed to process claims to all my insurance carrier(s) and its authorized agents. I authorize RidgeView Optometry to act as my agent in helping obtain payment from my insurance companies.
Assignment of Benefits:
I assign all payments, rights and claims for reimbursement of claims, costs and expenses allowable under my insurance plan(s) directly to my provider or practice for services rendered. I understand I will receive a statement for any balance due by me and I agree to make full payment upon receipt of the statement after insurance has met its obligation.
Agreement of Responsibility:
I understand that copayment is due at the time of service (coinsurance and deductibles may also be collected at the time of service). I understand I am financially responsible for charges not covered by my insurance company. I also agree to pay any outstanding balance as well as attorney fees and costs to RidgeView Optometry if this matter is referred to collection.
Medicare Authorization:
If a Medicare beneficiary, I understand my signature requests payment to be made and authorize the release of medical information necessary to pay claims. If ‘other health insurance’ is indicated in item 9 of the HCFA-1500 Form, or elsewhere on approved claim forms, or electronically submitted claims, my signature authorizes the release of information to insurance companies or their authorized agents. In Medicare-assigned cases, the physician or supplier agrees to accept the charge of determination of the Medicare carrier as the full charge, and I agree I am responsible for deductible, coinsurance and non-covered services. Coinsurance and deductibles are based upon the charge determination of the Medicare carrier.