As part of our services at this practice we are happy to assist you in determining the benefits of your individual policy and in collecting your reimbursement of insurance benefits for medical and vision services. To avoid any misunderstandings please read the following statements carefully:
- The legal obligations of your insurance provider are between yourself and your provider, not between this practice and your provider.
- When your insurance provider (s) has settled your plan’s covered items, you will be notified by a monthly statement if there were any unpaid balances. Unpaid balances can include non-covered items or services, co-pays, deductibles, lapses, ineligibility or termination of coverage. Unpaid balances are the sole responsibility of the patient.
- To keep the cost of records and collections down any patient portion amounts on your order will be due at the time of service.
- I authorize the use of this form for all insurance submissions authorizing the release of information to all of my insurance companies, in addition to allowing my doctor and his/her designees to act as my agent in obtaining payment from my insurance company.
- I authorize payment be made directly to the provider and permit a copy of this authorization to be used in place of the original.
REFUND & Return Policy
No refund can be made on clinical procedures or services, including comprehensive eye examination, refraction, contact lens fitting, and medical office visits. Optical products are custom made. Once prescription orders are made and processed, they are no longer returnable or refundable. Sunglasses are non-refundable.
Consent for Treatment
I hereby authorize Roland Park Vision to administer diagnostic and medical procedures as may be necessary for appropriate health care.
Notice of Privacy Practices
We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.