Payment Policy:
1) You are agreeing that if your payment for services and/or materials rendered is ever uncollectable (i.e. returned check or lapse of insurance coverage), you will be responsible for payment of any and all collection costs. You hereby agree to assume the responsibility of any remaining copayment and balances after payment is made that are not covered by your insurance. You hereby authorize release of any information with respect to your claim and certify that the information furnished in support of the claim is true and correct.
2) You are authorizing Hendersonville Eye Health & Vision, PLLC to disclose your name, address, telephone #, appointment dates and time for the purpose of recalling lists to remind you of your next appointment time and to provide you with product information.
Notice of Privacy Practices Acknowledgement:
I understand that I have certain rights of privacy regarding my protected health information under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:
1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
2. Obtain payment from third-party payers.
3. Conduct normal healthcare operations, such as quality assessments and physicians certifications. I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I understand that I may request, in writing, that you restrict how my private information is used to carry out treatment, payment, or healthcare operation. I also understand you are not
required to agree to my requested restrictions, but if you agree, then you are bound to abide by such restrictions.
Late Policy:
If a patient is more than 15 minutes late for an appointment, the appointment may need to be rescheduled. This is to ensure that the patients who arrive on time do not wait longer than necessary to see the provider. You may be given the option to wait for another appointment time on the same day if one is available. We will try to accommodate late‐comers as best as possible, but cannot compromise on the quality and timely care provided to our other patients.
Eyeglass Warranty:
I understand that in rare cases my eyeglass prescription may need to be tweaked after my eyeglasses are made. If I experience any discomfort or blur that lasts longer than a week of continual wear, Hendersonville Eye Health and Vision will be happy to re-evaluate my prescription to see if any changes need to be made to the prescription and re-make my updated lenses for free. I have 60 days from the date of purchase to contact the office. If I contact Hendersonville Eye Health and Vision after the 60 day mark, I will be responsible for the cost of any adjustments to my lenses. Please visit our website for additional details.
Contact Lenses Fitting Fee Agreement:
I understand that contacts are as unique as the patient wearing them. Because of this, if my prescription requires a little extra attention or extended parameters, I may be subject to an advanced fitting fee. This fee is still billable to my insurance but may be a little higher than that of a standard fit. Dr. Garnsey will assess my prescription to determine if this is necessary.
FTC Eyeglass Rule:
Each patient has the legal right to their prescription and that a printed copy will be provided at the completion of the exam.
Return Policy:
- Lens orders: Returned within 60 days of order are subject to a $35 or 20% restocking fee (whichever is greater). If insurance is used, fee will not exceed co-pays collected.
- Frame orders: Frame must be in like-new condition for return.
- Orders older than 60 days are no longer eligible for a refund.