Please complete the form below or click here to download a printable version.
Office Payment Policy
- Payment is expected the date of service.
- Payment may be made by cash, check, money order, or credit/debit card.
- Before glasses or contact lenses are ordered, half of the total charge must be paid. The balance is to be paid in full when the eyewear is picked up.
- All repairs are to be paid for when performed.
Office Policy for Insurance Billing
You are responsible for providing the most recent insurance card at the time of service. You are responsible for your portion of the charges at the time services are rendered. This includes all co-pays and deductibles. We will try to determine as accurately as possible what the insurance will pay, but you are responsible for the entire balance if insurance denies the claim. If it is not paid by the insurance company within 90 days of filling the claim, the balance becomes your responsibility. We will provide receipts for you to file for reimbursement.
Insurance Signature on File
I certify that the information given by me in applying for insurance and/or Medicare payment is true and correct. I authorize my doctor and or his/her staff to act as my agent in helping me obtain payment of my insurance benefits, and I authorize payments directly to Weigel Family Eye Care on my behalf for any services or materials received. I authorize the release of any medical information to the insurance company and its agents as necessary to determine the benefits payable to related services and materials. If I have other health insurance coverage, my signature authorizes release of the above medical information to the appropriate insurer or agency, and authorizes my doctor or his/her staff to act as my agent, as above.
I have read and understand the office policies as above.
"*" indicates required fields