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Acceptance of Insurance Benefits

  • At Bright Eyes Vision, we are happy to accept your insurance as payment for all covered services provided. When accepting your insurance at the time of service, we anticipate that your insurance company will reimburse Bright Eyes Vision for the services performed by our doctors. Nevertheless, even with prior authorization from your insurance company, the services provided by Bright Eyes Vision may not be covered, in full or in part, by your insurance policy. Your insurance company will only approve and pay for covered items and services. Your insurance will not pay for co-pays, deductions, and non-covered items and services.

    If your insurance company denies payment of your claim for services provided by Bright Eyes Vision, or if your insurance company pays you directly, you hereby acknowledge and agree that you are individually and personally responsible for full payment of the cost of items and services provided to you by Bright Eyes Vision.

    All copayments are to be paid at the time of service. This arrangement is part of your contract with your insurance company.


    By signing below, you agree to assign your right to receive insurance benefits to Bright Eyes Vision for the purpose of filing a claim for coverage of services provided. You further authorize Bright Eyes Vision to provide your insurance company with any and all medical information necessary for its determination of insurance coverage.

    If your account is more than 60 days past due you will get a late fee. After 90 days past due, your account will be sent to collections. It will the policy of this office to temporarily discontinue car for the patient and possibly immediate family members until your account is settled. If in fact you are discharged from this practice for any reason, you will at that time be notified by certified mail that you will have 30 days to find alternative medical care. During that 30 day period our physicians will be able to treat you only on an emergency basis.

    Our policy is to charge $50 for any missed Saturday appointments not canceled with 24 hours of the appointment time. Please help us serve you and others better by keeping your regularly scheduled appointments.

    We must obtain a copy of your driver’s license and current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information, or your insurance changes and you fail to notify us in a timely manner, you may be responsible for the balance of the claim. Most insurance companies have time filing restrictions; if a claim is not received within 30 days of the date of service, it can be rendered ineligible for payment and you will be responsible for any balance.

    Moreover, your signature below indicates that you understand and agree that you are solely responsible for providing Bright Eyes Vision with the correct and most up-to-date information about your insurance benefits.

    The agreements, assignments and authorizations provided by this form shall apply to items and services provided during all current and future visits to Bright Eyes Vision unless expressly revoked in writing
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