Appointment Cancellation, No-Show, and Rescheduling Policy

We value your time and ours. To provide timely care to all patients, we require advance notice for appointment changes.

Cancellations, no-shows, or reschedules made with less than 24 hours’ notice may result in a fee.

• First occurrence: $25 fee

• Subsequent occurrences: $50 fee

• Fees may apply regardless of insurance coverage and are the patient’s responsibility.

• Repeated missed appointments may result in limited scheduling privileges or dismissal from the practice.

Collections Policy

• Accounts with unpaid balances may be sent to a third-party collection agency.

• A $50 collections processing fee will be added to the outstanding balance if an account is referred to collections.

• Once an account is in collections, all future appointments may require prepayment.

Returned Check (NSF) Policy

Returned Check / Non-Sufficient Funds (NSF) Policy

If a check submitted for payment is returned by the bank for non-sufficient funds, closed account, stop payment, or any other reason, the patient or financially responsible party will be charged a $35 returned check fee in addition to the original amount owed.

The returned check fee is assessed to cover bank charges and administrative costs and is not billable to insurance.

All outstanding balances, including the returned check fee, must be paid in full before additional services or optical products are released.

After one returned check, the practice reserves the right to restrict future payments to cash, credit card, or debit card only.

If Unpaid or Repeated NSF Checks

Accounts with unpaid returned checks may be subject to additional administrative fees, referral to a collection agency, and restriction of future scheduling until the balance is resolved. A $50 collections processing fee will apply if an account is sent to collections.

Credit Card & Chargeback Policy (Custom Products & Services)

To protect patients and the practice, we maintain the following policy regarding credit card disputes and chargebacks:

Custom Optical Products (Glasses & Specialty Lenses)

• All eyeglasses, lenses, and specialty contact lenses are custom-made medical devices manufactured specifically for the patient based on their prescription and measurements.

• Custom products are non-refundable once ordered, regardless of insurance reimbursement, changes in preference, or patient non-pickup.

• By authorizing payment, the patient acknowledges that custom optical products are exempt from chargebacks under credit card network rules.

• Initiating a chargeback for a custom product may result in:

  • Immediate balance reinstatement

  • Suspension of optical services

  • Requirement of future services to be prepaid

  • Possible dismissal from the practice

Professional Exam & Medical Services

• Eye examinations, diagnostic testing, and medical services are professional services rendered at the time of the visit.

• Once services are provided, they are non-refundable.

• Insurance determinations do not alter patient financial responsibility.

• Chargebacks filed for services already rendered will be considered invalid disputes and may result in:

  • Reinstatement of charges

  • Transfer to collections

  • Restriction of future scheduling

Patient Financial Responsibility & Policy Acknowledgment

Patient Financial Responsibility Acknowledgment

I understand and agree that I am financially responsible for all services and products provided to me by this office. I acknowledge that appointment no-shows, late cancellations, and reschedules with less than 24 hours’ notice may result in fees as outlined in the office policies.

I understand that returned or dishonored checks are subject to a $35 fee and that future payment by check may be restricted.

I understand that eyeglasses, lenses, specialty contact lenses, and other optical products are custom-made medical devices and are non-refundable once ordered.

I further understand that insurance coverage is not a guarantee of payment. Any services or products that are denied, reduced, reclassified, or deemed non-covered by my insurance for any reason—including medical necessity determinations, benefit limitations, frequency limits, or plan exclusions—become my personal financial responsibility.

I understand that eyeglasses, lenses, and specialty contact lenses are custom-made to my prescription and measurements and therefore cannot be returned, refunded, or reversed once ordered, regardless of insurance reimbursement or personal preference.

I further understand that professional eye examinations, diagnostic testing, and medical services are considered rendered at the time they are performed and are non-refundable.

I agree not to initiate a credit card chargeback for valid charges related to custom products or services already rendered. I understand that initiating a chargeback does not relieve me of financial responsibility and may result in:

• Reinstatement of the full balance

• A $50 collections or administrative fee if sent to collections

• Suspension of optical services

• Requirement that future services be prepaid

• Possible dismissal from the practice

I acknowledge that I have had the opportunity to ask questions regarding charges prior to authorizing payment.

By signing below, I acknowledge that I have reviewed, understand, and agree to all office and financial policies.