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Financial Policy

  • Date Format: MM slash DD slash YYYY

  • *INSURED PATIENTS

    Your insurance policy is a contract between you and your insurance company. It is our responsibility to interpret your benefits at the time of your visit. It is your responsibility to provide us with the name of your current insurance and member ID. Please be aware that not all services may be covered by your insurance. You will be responsible for non-covered services. If we are a non-provider for your insurance company, you will be responsible for 100% of the charges.
  • You will be responsible for 50% of the total charges if your materials need to be ordered and the balance paid in full at the time the materials are dispensed. You will be responsible for 100% of the charges if your materials are in stock and dispensed the day of the exam.

    *INSURANCE SIGNATURE ON FILE

    I certify that information given by me in applying for insurance and/or Medicare is accurate. I authorize the staff at 20/20 Vision Care to act as my proxy in helping me obtain payment from my insurance company. I authorize any holder of medical information about me to release in the Centers for Medicare and Medicaid Services to aid in any information needed to determine benefits payable to services. If I have secondary or any other insurance, my signature releases the above medical information and authorizes the staff at 20/20 Vision Care to act as my agent.

    *MEDICAL WAIVER

    I understand that if/when Dr. Zarky Rudavsky and Dr. Meghan Sullivan perform medical exams and procedures, these services will be billed to my medical insurance. I also understand that it is my responsibility to pay any deductibles and/or co-payments that the insurance company requires. I also understand that not all services may be covered by the insurance policy and those charges will then be my responsibility.
  • *NON-INSURED PATIENTS

    Exams and testing must be paid in full on the date services are completed. You will be responsible for 50% of the total charges if your materials need to be ordered and the balance paid in full at the time the materials are dispensed. You will be responsible for 100% of the charges if your materials are in stock and dispensed the day of the exam.

    *POLICY AGREEMENT

    I have read and fully understand the content of 20/20 Vision Care's Financial Policy. By signing below, I agree to the content of this policy and understand my responsibilities.
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY