Thank you for choosing Pine Creek Vision Clinic for your vision care. In order to provide the best care possible for all our patients we request that you take the time to carefully review our office policies. Listed below, you will find our policies concerning COVID-19, scheduling, appointments, financial arrangements, and missed appointments.

NOTE: Some of these policies are new, we highly suggest you take the time to read this form in its entirety. Services cannot be provided until this agreement is signed by the patient or patient’s legal guardian. By signing this agreement, you acknowledge that you are responsible for all charges/fees that may apply. Thank you for your cooperation.

COVID-19 Safety Protocol:

As a healthcare organization we must comply with safety, health standards and regulations. Therefore, safety and care of our staff and patients is an obligation and top priority for the practice.

PCVC will maintain a strict cleaning and disinfecting protocol. We want to assure our patients that the exam lanes, equipment and office will be continually sanitized and handled with the most caution.

Cancellation and No-Show Policy:

Exam slots are limited and valuable. To serve our patients better, we ask for proper notice for any cancellations. All patients are required to provide at least 24 hours advance notice when cancelling an appointment so that we may provide other patients with care. We understand that you may miss your appointment due to an emergency, for this reason we also reserve the right to asses each situation on a case by case basis. While we do provide reminders the day before the appointment it is the patient’s responsibility to remember the appointment

Patients failing to provide at least a 24-hour notice (“Same Day Cancellation”) or giving no notice at all (“No Show”) will be charged a $30.00 fee for a missed appointment. After three (3) missed appointments, the practice may at its discretion, choose to discontinue your care.

All fees must be paid before a new appointment can be scheduled.

Late policy:

If you arrive more than 10 minutes late to your appointment you will be asked to reschedule your appointment, unless the doctor’s schedule can accommodate you.

Priority will be given to patients who arrive on time and you may have to be worked in between them.


As a practice we participate in most major insurance plans, including Medicare and Medicaid. It must be understood that if you are insured by a plan we are not in network with or we cannot verify coverage, payment in full will be expected at the time of your appointment. Knowing your insurance is your responsibility. Please contact your insurance company prior to your appointment with us to clarify your coverage/benefits.

Co-payments, Deductibles, and Co-insurance:

All co-payments must be paid at the time of service. This arrangement is part of your agreement with your insurance company. Failure on our part to collect co-payments, deductibles, and co-insurance from patients can be considered fraud. Please assist us in upholding the law by paying your insurance costs at each visit.

Self-pay Services:

Self pay patients will receive our self-pay discounts tailored to each service. All charges must be paid in full at time of services rendered. If you have any questions or concerns regarding specific charges or discounts, please ask our staff members prior to receiving services to assure both parties are aware of what will need to be collected on the date of service.

Non-Covered Charges:

Please be aware that even if we do take your insurance, we still offer services that are not covered by any insurance company. If you decide to receive a non-covered service, it must be paid the same day, in full. We will not bill any of the non- covered services to your insurance company. These will be the patient’s responsibility entirely. If you have any questions or concerns regarding which services will not be covered by your insurance, please ask a staff member or your doctor prior to receiving care. We will be happy to provide clarification needed.

Referral and Pre-Authorization:

It is your responsibility to ensure that any referrals, or pre-authorizations required by your insurance company be provided to our office prior to services being rendered. Failure to obtain required referrals or authorizations will result in you being responsible for the full balance.

Proof of Insurance:

All patients must complete our patient information form prior to seeing the doctor. A current and valid insurance card must be presented at time of service. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of the claim.

Insurance Information:

Payment is required when services are rendered, or when materials are ordered. Quotes of insurance coverage are based on information from the insurance company and are not guaranteed. Although we will gladly bill insurance for you, patients remain responsible for their charges even after insurance has been billed. If payment has not been received from insurance after 60 days, the patient will be expected to pay Pine Creek Vision Clinic. Pine Creek Vision Clinic does not bill secondary insurance. If the claim does not cross over, it is the patient’s responsibility to bill insurance.

Please be aware that the balance of your claim is your responsibility whether your insurance company pays your claim or not. Your insurance benefit is a contract between you and your insurance company. We are not a part of that contract.

Optical Policy:

Eyeglasses are custom order prescription medical devices, therefore, are non-refundable. Patients have 90 days to pick up orders unless an alternative agreement has been made.

Patients have 90 days after the prescription is filled to come in for a complimentary refraction if the prescription is not working. A one-time lens remake within the 90 days, is considered if we determine the prescription needs to be adjusted. It will be the patient’s responsibility to replace glasses if they are lost or stolen, regardless of the 90-day period.

If a patient leaves without taking their own lenses or declines to take them after picking up their new glasses, Pine Creek Vision Clinic is not responsible to hold or replace them.

Although we always exercise the greatest of care, we are not responsible for the patient’s own frame should it break while we are adjusting, repairing or reusing it for a new prescription. This includes frames that are purchased elsewhere and brought to us and non-prescription sunglasses.

Contact Lens Fit:

A contact lens evaluation is a necessary and state regulated service in order to ensure the proper fit of a contact lens. The evaluation is an additional service to the comprehensive eye exam and has a separate fee that will cover the initial evaluation and all contact lens related follow-up visits for a period of 90 days from the original appointment. This can range anywhere from $90-$1,000 depending on the complexity and type of evaluation. We do not offer refunds on ordered contact lenses.

The higher fees for a contact lens fitting are for specialty contact lenses. If your provider thinks you may be a candidate for a specialty lens, please inquire at the front desk for additional information on fees that may apply.

We thank you for your cooperation and for trusting Pine Creek Vision Clinic with your vision needs. We look forward to providing you with the best quality of care!