Financial Policy

Forms/Financial Policy.doc 7.08

Payment of all services and materials are payable at the time of your visit. If you have health insurance, we will give you a super bill with the necessary codes, but we do not bill our patients or their insurance companies.

Credits for returned materials and cancelled orders are issued as Store Credit ONLY. There is a 15% restocking fee for all returned materials and cancelled orders. All orders for eyeglasses, sunglasses and contact lenses are final sale, once the order has been processed at the lab, within 24 hours of the order (these are prescription orders). We are NOT responsible for any materials left in our office over 90 days.

We cannot accept your insurance as payment unless you have a specific vision plan, for which we are providers. In that case, you will be responsible for your co-payments, and any additional charges for services that are not covered by your insurance company.

If we are a provider on your insurance panel, we will give you an estimate of your co-payment. We will know the exact amount only after we bill your insurance company, and they have issued an explanation of benefits with payment.

Your insurance is a contract between you, your employer, and the insurance company. We are not a party of that contract.

Not all services and materials are covered in all insurance contracts. Some insurance companies arbitrarily select certain services they will not cover. We cannot render services or provide materials on the assumption that our charges will be paid by your insurance company. You are responsible for non-covered services and materials.

There are additional fees for contact lens evaluations and follow up visits.

I understand and agree to these policies.

Insurance Explanation

If the Hollywood Vision Center is not on your vision or health insurance, this is considered an out-of-network visit.

  1. Please note that professional services are rendered and charged to the patient and not to the Insurance Company. You are responsible for service and materials fees.
  2. Your insurance company may reimburse you depending on your eligibility and plan, but we are not responsible for collecting from your insurance company.
  3. Payment is expected when services are rendered for all patients.
    Even if an insurance claim is filed, you will receive a statement each month if your account has a balance due. This office cannot accept responsibility for collecting your insurance claim or for negotiating a settlement on a disputed claim. You are responsible for payment of your account within the limits of our credit policy.
  4. We can give you a super bill listing services and materials rendered to attach to the claim form provided by your insurance carrier.
    Please contact your insurance company representative or medical plan carrier for claim form. Fill in your part of their form (usually part 1 or part A). Attach the superbill and mail it to the insurance company or health plan office according to their instructions.
    A doctor’s signature is not required. This form is authentication in itself.
    It is not necessary for this office to fill out the insurance claim. Our customary fee will be charged for additional itemization of services.
  5. If you have any questions we will assist you. Your insurance carrier will determine your eventual reimbursement.
I understand and agree to these policies.
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