Financial Policy Form

Financial Policy Form

Financial Policy Form

We are committed to providing you with the highest quality care and are pleased to discuss our professional fees with you at any time. Your clear understanding of our financial policy is important to our professional relationship. Please ask if you have any questions about our fees and financial policy or your responsibility.

No Show: No shows and short notice cancellations are a significant problem for small practices like ours. Many practices overbook on purpose so that no shows and cancellations won’t limit access for other patients as well as cause a financial hardship for the practice. We feel this is unfair for those patients who do show for their appointments on time. Therefore, we may assess a $40 cancellation fee for patients who do not show for their appointments. Patients are considered a no show if they are more than 10 minutes late for their appointment or if they do not give at least 24 hours notice for cancellations. Today’s Vision Bulverde reserves the right to dismiss patients from the practice if they repeatedly violate this policy.

Cell Phone Policy: We respect your time and ask that you respect ours. As such, we ask that you refrain from taking phone calls during your exam. This includes participating in teleconference calls, even if “just listening in”. If you MUST participate in such a call you will be asked to reschedule and charged our $40 cancellation fee.

Insurance: All medical and vision insurance information must be presented prior to or at the time of the appointment. We will not take any insurance information after services have been provided, therefore, you will be responsible for full payment of services.

We will file your insurance claim but you are responsible for the following

  • obtaining appropriate referrals, if needed, prior to the appointment

  • co-payments, deductibles, co-insurance, or services not covered by contracted carriers

  • any balances remaining between our charge and the insurance payment

  • providing Today's Vision with up to date insurance information


Our staff will assist in dealing with your insurance company by verifying your benefits; However, this verification does not guarantee payment from the insurance company and not all services are a covered benefit in all plans. It is your responsibility to know and understand your own insurance benefits, coverage, and authorization requirements.

We cannot waive co-payment, deductibles, co-insurance or non-covered services amounts defined as patient responsibility under the term of your contact with various health plans. Payment of co-payments and any non-covered services are due at the time of service. Please be ready to make a payment on the day of your appointment. Any remaining balance on your account after the insurance company has processed your claim is due upon the receipt of the statement from our office. Filing a claim does not guarantee payment from the insurance company. It is our policy to file claims for services rendered through primary medical insurance, if benefits available, prior to vision service plans. This is because vision plans are considered supplemental coverage in Texas.

Method of Payment: It is customary to pay for professional services when rendered. For your convenience, we accept major credit cards, cash, or checks. There will be a $30 charge for all returned checks.

Insurance Authorization and Financial Responsibility
Assignment of Insurance Benefits –
I certify that the insurance information given by me is, to the best of my knowledge, correct. I hereby authorize and assign payment to Swift Eye Care DBA Today's Vision Bulverde of all benefits due and payable under the terms of my policy. I also authorize Today's Vision Bulverde to release medical or other personal information to my insurance company(ies) now or in the future for claim consideration purposes.

Financial Responsibility – I understand that I have financial responsibility for all charges and those charges not paid by insurance or their party payers. I hereby assume full responsibility for all services rendered to the patient including any charges not covered by insurance and such interest and financial charges imposed according to Today's Vision Bulverde's policy. I am aware that I will be billed by Today's Vision if my insurance does not pay for the services rendered. I understand that payment is due at the time services are rendered.

Contact Info

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