Colvard-Kandavel Eye Center is committed to serving our patients with caring professionalism and concern. We expect our patients to assume their commitment to adhere to our practice policies. These include being on time for your appointment and calling 24 hours in advance to cancel an appointment. There may be a Thirty dollar ($30.00) charge to your account if you cancel your appointment with less than a one business day notice.
Patients also have a duty and responsibility for the payment for any services rendered. As a courtesy we will bill your designated health insurance carrier and attempt to collect for such services. We cannot guarantee your coverage and ultimately you are responsible for paying for services and materials rendered in good faith to you by our staff at the time of service. This includes co-pay’s, deductibles, contact lens evaluations and fittings and refraction fees as well as any cosmetic or other non covered services.
At the time of each visit to our office, you will be asked to present your current identification, primary and secondary insurance cards and advise us if you have a vision plan. This will ensure proper billing to your insurance carrier(s). You also agree that if eligibility cannot be verified with the Insurance you have provided, you will then be responsible for the payment in full of those charges at the time of service.
Medicare patients: You authorize payment to be made on behalf of Valley Eye Institute, Inc. for any services provided to you by any VEI provider. You authorize our providers to release all medical information to the Centers for Medicare and Medicaid Services and its agents needed to determine these benefits or the benefits payable for related services. You understand that your signature below directs that payment be made directly (assigned) to the provider (VEI) and authorize release of any medical information necessary to pay the claim. VEI accepts the charge determination of the Medicare carrier as the full charge but you agree that you are responsible for the deductible, co- insurance and non-covered services. These fees are the amounts agreed to in the provider’s Medicare agreement.
You authorize all insurance benefits to be made on your behalf (assigned) to VEI.
I understand that my signature directs payment be made from the carrier directly to VEI to pay my Medicare or commercial insurance claim and authorizes the release of medical information necessary to facilitate the payment of medical services rendered by VEI.
Please read, initial each blank and sign where indicated – this document describes your financial responsibilities.
This is a legally binding contract between Valley Eye Institute and you. The words, I, me, my, you and your all refer to the patient.
Valley Eye Institute is currently using secure Compulink Electronic medical records and is directly interfaced with Vantiv merchant services for credit card processing. We would like your permission to keep your credit card on file electronically. Only merchant service has your entire credit card number and it is not stored in your electronic medical record. Strict guidelines and security measures are taken by Vantiv merchant service and Compulink to ensure your data is safe.
We would further like your permission to process credit card payments for due or past due balances. If you wish NOT to keep your credit card on file, please advise our staff .
You may cancel this authorization at any time by contacting us at:
I have read and understand the above and I authorize Valley Eye Institute to keep my credit card on file and I further authorized Valley Eye Institute to process payments on my account.
I hereby authorize payment of medical benefits under my health coverage directly to Valley Eye Institute. This is a DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS. This authorization will remain in effect until canceled by me in writing. A copy of this authorization is as valid as the original document.
I authorize the release of any medical information necessary to in order to obtain payment and I understand that I am financially responsible for all charges, late fees, interest, attorney fees and collection charges considered patient responsibility by my insurance company. I understand that if I am not insured I am responsible for the charges on all services provided to me. I authorize VEI to deposit checks received on my account when issued in my name.
I have read and understand VEI’s Assignment of benefits and I accept responsibility for the payment of any fees associated with my care.
Colvard-Kandavel Eye Center offers personalized eye care services for patients with routine and complex eye conditions.
Our team is here to help you make an appointment with the specialists that you need.