FINANCIAL POLICY
This policy outlines the financial terms and conditions associated with your care at Monson Vision.
By checking the acknowledgment box, you confirm that you have read, understood, and agreed to the following terms:
Charges and Payments. You agree to pay for all services rendered. Future visits may require payment at the time of service if account privileges are revoked.
Credit Card on File. You authorize Monson Vision to securely retain your credit card information on file. This card may be charged for no- show fees, returned checks, refraction fees, deductibles, co-payments, co-insurance amounts, outstanding balances, and any other fees not paid at the time of service. Please ensure your credit card information is current.
Surgery Fees. A $550 facility fee per eye is due at least 72 hours before surgery. For both eyes, the total fee is $1,100. Failure to pay may result in surgery cancellation. If you do not cancel surgery at least 72 hours prior, the fee becomes non- refundable. However, the fee will be applied to your surgery if it is rescheduled for a later date.
Appointment No-Show Fees. Appointments not canceled or rescheduled within 24 hours will incur a $25 no-show fee.Refraction Fees. A $40 fee applies to refractions if not covered by insurance. This is a standard part of eye exams but is typically not reimbursed by insurance or Medicare.
Insurance Responsibility. We bill your primary and secondary insurance as a courtesy. However, you are responsible for any unpaid balances, co-payments, deductibles, and non-covered charges. Payment is required within 60 days if insurance does not remit payment.
Self-Pay Patients. If you do not have insurance or choose self-pay, the full cost of your exam ($125) or surgical procedure is due at the time of service.
Returned Checks. A $25 fee will be charged for returned checks.
Outstanding Balances. Balances unpaid by the due date may accrue interest at 18% annually. Accounts sent to collections may incur additional fees, including court costs and attorney fees.
Divorce and Separation. The parent or party authorizing treatment is responsible for all charges. Collection from other parties, if required by divorce decrees, is the authorizing party's responsibility.
Monthly Statements. Statements detailing charges, payments, and balances will be sent for any outstanding accounts.
Communication Consent. You authorize us to contact you via phone, text, or email regarding account servicing and payment collection.
