I am the patient or the patient's duly authorized representative, and do hereby, voluntarily, consent to and authorize care encompassing all diagnostic and therapeutic treatment regimens necessary in the judgment of my provider, for myself, my minor child, or other. I am aware that the practice of medicine is not an exact science. I acknowledge that no guarantees have been made to me as a result of treatments or performed examinations.

I do, hereby, authorize the release of medical information necessary to file a claim with my insurance company and assign benefits otherwise payable to myself and Jax Vision Care, P.A.

I have been provided the opportunity to read, or have it read to me, the Notice of Privacy Practices at Jax Vision Care, P.A. I understand how information and records may be used and disclosed. I understand that my health record is the physical property of Jax Vision Care, P.A., but the information belongs to me. I have a right to obtain, inspect, and amend a copy of my health record. Any costs associated with this will be my responsibility and must be paid prior. Written requests must be made to the Privacy Officer. I understand that Jax Vision Care, P.A. is required by law to maintain the privacy of my health information. They will require my written authorization to release my information to outside sources with the exception of disclosures for treatment, payment and healthcare operations. These disclosures may include: access to my information by Jax Vision Care, P.A. staff and doctors; billing to me or a third party; in addition, business associates of Jax Vision Care, P.A. Upon the physicians’ best judgment, Jax Vision Care, P.A. may disclose to a family member, relative or close personal friend or any other individual I identify, health information relevant to that person’s involvement in my care. Health information may also be used for research data, organ procurement, marketing, FDA, public health or legal authorities and/or law enforcement authorities. Jax Vision Care, P.A. may call or write me with appointment reminders, cancellations and may leave voice mail messages at home or place of employment as well as on my mobile phone.

• For some insurances, we accept assignment of benefits, but in ALL cases, the patient or person responsible (guarantor), is liable for all balances or procedures not covered by insurance.
• Some, perhaps all, services provided may not be covered under Medicare guidelines which most insurance companies follow.
• If insured with a plan we do not participate with, full payment is due at the time of service(s).
• If unable to produce government issued, picture identification, full payment is due at the time of service.
• It is the responsibility of the patient or responsible party to inform JVC staff or any changes to insurance or patient demographics. Failure to do so may result in payment being the responsibility of the patient.
USUAL AND CUSTOMARY RATES:
• We charge usual and customary rates for our specialty and region to insurance companies and patients. We reserve the right to charge the difference to the patient if the insurance pays on a different fee schedule.
CLAIM SUBMISSION:
• We will file claims to your insurance company as a service to you. It is the responsibility of the patient to comply with any requests from the insurance company.
• If the insurance company fails to pay the claim(s) within 45 days, it may become patient responsibility.
• I do authorize the release of medical information necessary to file a claim with my insurance company and assign benefits to Jax Vision Care, P.A.
DELINQUENT and PAST DUE ACCOUNTS
• In rare situations, payments may be allowed to be paid after services are rendered. If balances are delinquent or past due a $15 billing fee may be accessed to the patient’s account and must be paid prior to next appointment.
• The billing fee will be accessed each and every month that the account is not in good standing.
• JVC reserves the right to submit delinquent accounts to a collections agency. Once this process has started, treatment and appointments will need to continue elsewhere. JVC will continue to see the patient for emergency situations for up to 30 days on a cash only basis.
The patient will be responsible for any all additional fees incurred by JVC while seeking payment including, but not limited to, attorney fees, court costs, collection fees, etc. CANCELLATION AND APPOINTMENT POLICY:
• 24 hour notice is required to cancel or reschedule an appointment to avoid a $25 fee.
• Failure to arrive to a scheduled appointment will also result in a $25 fee.
• We reserve the right to reschedule any patient who arrives late to an appointment and the cancellation fee may be applicable.
• In some cases, these fees must be paid PRIOR to rescheduling.
CO-PAYMENTS AND DEDUCTIBLES:
• All co-pays and deductibles are due at the time services are rendered. Paying these fees are part of your contract with your insurance company.
• Failure to do so could result in the $15 billing fee.
PAYMENTS:
• Checks returned for any reason will result in a $35 fee that must be paid in cash or by credit card prior to receiving materials or making an appointment in addition to the fees incurred by JVC from the bank. Failure to do so may result in legal action.
• Forms of accepted payments: VISA, MasterCard, American Express, Discover, CareCredit, cash and checks. Temporary or starter check will not be accepted.
REFRACTION:
• Must be performed for a complete eye exam and is the best way to yield your eye glasses prescription.
• It is covered by most vision insurances during the annual exam depending on the policy.
• It is not covered by Medicare and therefore is not covered by most medical insurances for medical visits. If it is needed for a medical visit and is not covered, the fee is $35 and will be due at the time of service.
CONTACT LENSES:
• For patients using insurance for any portion of their contacts: After 2 weeks, your exam and fit will be filed to your insurance, most likely exhausting your contacts lens benefits
• Patients may return to finalize their contact lens prescription within 60 days at no additional charge.
• Patients may return between 60 and 90 days to finalize their contact lens prescription for a $35 fee.
• Any monies paid for fittings, finalized or not, are forfeited.
• Once contacts are ordered and arrive, we will contact you immediately. Once a patient is notified, contact lenses must be picked up within 90 days. After 90 days, the contact lenses will be returned and any and all monies paid will be forfeited.
GLASSES:
• Any orders on hold for payment not completed within 30 days will be returned to inventory and any monies paid will be forfeited.
• Once an order is started, no changes affecting the finances can be made. All orders are final.
• Once glasses are ordered and arrive, we will contact you immediately. Once a patient is notified, glasses must be picked up within 90 days. After 90 days, the glasses will be returned and any and all monies paid will be forfeited.
• The glasses that are provided are custom to each patient, therefore NO REFUNDS shall be given.
• Jax Vision Care, P.A. (nor any of the optical labs we work with) does not accept any responsibility for damaged or lost frames during the shipping or fabrication process that are provided by the patient. This also includes frames/lenses that may be damaged during the adjustment or repair process at our office or off-site lab.

I have read and understand ALL of the above policies for Jax Vision Care, P.A. I have been given or will take the opportunity(s) to ask questions or express any concerns. I also attest that any and all information provided by me is true and accurate to the best of my ability.

Patient/Legal Representative Signature: