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Financial Policy Form

Notice of Privacy Practices Acknowledgement (HIPAA)

Our notice of Privacy Practices provides information about how we may use and release protected health information about you. You have the right to review our notice before signing this form. As provided in our notice, the terms are subject to change. If we change our notice, you may obtain a copy by writing to our office with your request.

You have the right to request that we restrict how your protected health information is used or released for treatment, payment or health care operations. We are not required to agree to this restriction but, if we do agree, we are bound by our agreement.

By signing this form, you consent to our use of protected health information as described in our notice. You have the right to revoke this consent in writing, with the exception of where we have already made releases in reliance on your prior consent.

Assignment of Benefits

I hereby assign and authorize benefits for services rendered to me to be paid directly to Georgia Vision Center as indicated by my signature following the office policies. I understand that verification of insurance benefits is not a guarantee that benefits will be paid. I further understand that my health insurance company may not cover all or part of the medical services rendered and that I am financially responsible for and agree to pay all charges not paid by my health care coverage. I understand that Georgia Vision Center may file my insurance as a courtesy; however, I am ultimately responsible for payment of all services rendered. I authorize the release of medical information required to process the claims for payment of the services rendered. A copy of the assignments shall be considered as valid as the original.


Refraction is the test that measures a person's prescription for eyeglasses. It is also used to check or update an old prescription. The refraction helps to determine if your vision condition is an optical condition or possibly a medical condition. Optical conditions include farsightedness, nearsightedness, astigmatism and the inability to focus on near objects that develop with age. Medical conditions may include infections, macular degeneration, glaucoma and cataracts.

This test is usually covered by routine vision plans. However, it is not always covered by health care insurances. It is considered a separate procedure. Medicare does not pay for the refraction. It is considered a non-covered service. Our fee for this procedure is $45.00 payable at the time of service. The only exception is if we are aware that your insurance company has paid for this procedure in the past.

Your signature, following our policies, indicates you understand that in the event the refraction test is considered a non-covered procedure by your insurance company that you will be responsible for the $45.00 charge at the time of service.

Payment Policy

Payment is due at the time of services. As a courtesy, we will file the insurance for you provided you have given us your insurance information at check in and provided our services are covered under your insurance plan. If we are filing your insurance, we will bill you for any charges that the insurance company deems patient responsibility. Please note, with the exception of vision plans which allow for annual visits, most routine eye exams are not covered by medical insurances unless there is a medical diagnosis. If you do not have a vision plan, please be prepared to pay for your exam should it be billed as a routine visit. There will be a $30.00 charge on all returned checks. Should the account be referred to an attorney or magistrate for collection, the undersigned shall pay all attorney's and collection fees. Your signature following our policies indicates that you understand our payment policy fully.


All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.