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Payment Policy Form

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Thank you for choosing us as your primary eye care provider. We are committed to providing you with quality and affordable health care. Our policy is to require payment in full at the time services are rendered. We realize every person's financial situation is different, and for this reason we offer a variety of payment options. Please read our policy and do not hesitate to ask any questions you may have.


Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don't have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Depending on your insurance coverage, we may not participate in non-benefit covered discounts. We will do our best to assist you with your insurance, but we highly recommend contacting your insurance company for more information on your coverage.

All patients must verify their insurance and demographic information at the time of scheduling. We will submit your claims and assist you in any way we reasonably can to get your claim paid. Please be aware that the balance of your claim is your responsibility. Your insurance benefit is a contract between you and your insurance company, we are not party to that contract.

Copayments & Deductibles. All co-payments and deductibles must be paid in full at the time of service. This arrangement is part of your contract with your insurance company. Failure on our part to collect copayments and deductibles from patients violates our contractual relationship with your carrier. Please pay your copayment at each visit.

Non-Covered Services. Please be aware that some - and perhaps all - of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. It is your responsibility to know what may or may not be covered. Our office will do its best to assist you with this information. You must pay for theses services in full at the time of visit.

Coverage Changes. If your insurance changes, please notify us before your next appointment so that we can make the appropriate changes to help you maximize your benefits. If the insurance company does not pay your claim in 45 days, the balance will automatically be billed to you.

Nonpayment. If your account is 90 days past due, you will receive a letter stating that you have 20 days to pay your account in full. Partial payment will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you and your immediate family members may be discharged from the practice.

Missed Appointments. We request that you cancel your appointment within 24 hours. After the second missed appointment without cancelation we will require a deposit of $25.00 in order to schedule. Please help us serve you better by keeping your regularly scheduled appointment.

Purchasing Materials. It is our policy to collect half down prior to ordering any contact lenses or eyeglasses. Payment in full is required prior to dispensing these materials.

Optical Exchange & Refund Policy. Here at Nittany Eye Associates we want you to be happy with your glasses. If you are not 100% satisfied, we offer a 30-day exchange or return policy from the day you receive your order. Depending on Insurance, some restrictions may apply. Please be sure to talk with the optician regarding your specific plan and the exchange and refund policy.

Patient Acknowledgement and Agreement*
I have read and understand the payment policy and agree to abide by its guidelines
Name of Patient or Responsible Party*
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