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. In order to keep a safe environment, we require all patients, children included, and employees to wear masks at all times when in the office. Due to limited supply, we will not be providing masks for patients in the office and if the patient chooses to arrive without a mask, the appointment will be rescheduled. Employees will be continually washing their hands and sanitizing throughout the day. PCVC requests that you wash your hands prior to entering the office and avoid any unnecessary touching.

In an effort to prevent the spread, we ask that if you have any fever or respiratory symptoms, you or someone you live with have traveled domestically or internationally within the last month, or have been in the presence of someone with COVID-19, that you cancel and wait to schedule your appointment for an additional two weeks.

In an effort to maintain a low number of patients and employees in the office at a time. PCVC will only allow the patient and, if necessary, their caretaker to attend the appointment. The waiting room is no longer available, and any family or company is required to wait in their car. PCVC also requires patients to wait in their car until their appointment time. If patients arrive more than 5 minutes prior to their appointment we will ask them to wait in their car. This applies to multiple family member appointments. Once the appointment has been concluded, patients will be expected to wait for their family in their car.

PCVC requires all paperwork to be filled out and submitted to the office the day before the patient’s exam. To minimize viral spread, paperwork will be sent by email or text prior to your appointment in an electronic format. If you experience any difficulties with the electronic format, please contact the office. Forms can also be printed off our website at and emailed to or faxed to the office at (719)694-8562. Patients will not be able to fill out forms in the office and if we do not receive the forms prior to the appointment we will have to reschedule for a later date.

PCVC requires patients to check their temperature the morning of their exam. If the temperature is higher than 98.9 degrees, we require you to call and reschedule your appointment and the cancellation fee will be waived. At designated appointment time, patients will be welcomed into the office. Staff will verify that the patient is wearing a mask and an employee will check the patient’s temperature, and if applicable, the caretaker. If the temperature is over 98.9 degrees, the patient’s appointment will be rescheduled and advised to speak with their primary care physician. We advise all patients to remain at least 6 feet from one another.

PCVC will be avoiding paper transactions as much as possible. At check out, patients will be emailed a link to their patient portal. On the portal, the patient will have access to their exams, receipts and prescriptions. If you would like this information prior, please call our office to get set up.

PCVC Optical will no longer be available on a walk-in basis. All visits to Optical will have to be scheduled prior to visiting the office. Patients can schedule themselves through their patient portal at or call the office to be scheduled. This includes all patient pick ups, adjustments and orders.

PCVC will have protocols in place for ordering glasses, adjustments and troubleshooting. Patients coming in for optical will also be required to wear a face mask, wash their hands and check their temperature.

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 patients 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:

All patients are asked to wait to enter the office until 5 minutes prior to their scheduled appointment time. In order to maintain social distancing and a timely schedule, 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. This may mean you will have a considerable wait time.


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. The patient must pay at least half of the cost prior to the optician ordering the glasses. No cancellations are recognized once the process has been started. A re-stocking fee will be applied to the patient’s account if it is cancelled for any reason. In addition, patients have 90 days to pick them up, 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. If the prescription needs to be adjusted due to our mistake, one lens remake in the same frame that was purchased from the original order will be covered. If the patient calls after the 90 days, stating that the prescription needs to be changed, it will be the patient’s responsibility to pay for the new lenses and refraction. It is the patient’s financial responsibility to replace glasses if they are lost or stolen, regardless of the 90-day period.

On occasion, a patient may need to change frames after an order has been placed. If this should occur, a re-stocking fee will apply. There are limitations and possible charges that are up to the optician’s discretion.

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.

For Neuro Optometric Rehabilitation, Dr. Saxerud and Dr. Wilson may use therapeutic techniques and lenses which may result in multiple pairs of lenses. This is the responsibility of the patient.

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. When contacts are purchased in office, we can offer exchanges for different contacts if needed. Please let it be known that in order to exchange contact lenses, the original boxes must be unmarked, unopened, and undamaged. No exceptions. We do not offer refunds.

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!