Notice Of Patient Privacy Rights, Protection & Responsibilities
Services Without Referral Authorization
As a valued patient of The Dry Eye Studio, you acknowledge that if your vision insurance does not cover the services provided during your visit today, you will be fully responsible for any charges incurred. Please be aware that certain services may not be covered under your plan, and in such cases, you agree to assume financial responsibility.
Medical Necessity
Should your insurance provider determine that any medical service or material is not covered, you understand that you have been informed and will take full financial responsibility for these specified services or materials.
Copays
It is essential that all copayments be made at the time of your appointment, prior to leaving the clinic. Please note that these payments are mandatory and cannot be waived by the healthcare providers or The Dry Eye Studio.
Deductibles
If your insurance provider indicates that your deductible has not been met, you agree to fulfill the payment in a timely manner, within 30 days of notification from either your insurance or The Dry Eye Studio. Annual deductibles are non-negotiable and must be paid as required.
Professional Services and Materials
You understand that you are responsible for the full payment of all professional fees on the date of service. If you are using your own frames, please be aware that materials like plastic and metal can degrade over time. The Dry Eye Studio and your insurance provider cannot be held liable for any accidental breakage during the lab process. Additionally, if you do not collect your materials within 60 days of your initial order, they will be returned to the laboratory, and your deposit will be forfeited. For those receiving contact lenses by mail, full payment is required at the time of service.
Patient Satisfaction Assurance
At The Dry Eye Studio, our commitment to patient satisfaction includes our high-quality single-vision and progressive lenses. We utilize premium optics and progressive lenses, often referred to as no-line bifocals. Although rare, if you experience difficulty adjusting to these lenses, we will remake them once in the same frame. Should the issue persist, we will offer a replacement with either lined bifocals or single-vision lenses, again using the same frame. While we strive to address these uncommon concerns, refunds will not be provided if adaptation to the lenses does not occur.
HIPAA Compliance
In accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have been provided with information regarding your privacy rights concerning your protected health information. You understand that this information may be used to coordinate your treatment, facilitate payment from third-party payers, and support standard healthcare operations, including quality assessments and professional certifications.
