Conditions of Treatment
I acknowledge receipt of 20Twenty’s Notice of Privacy Practices. I will refer to the Practice’s Notice of Privacy Practices regarding the release of my health information. I authorize the practice to communicate with me by phone, text or email, and to leave general messages on my voice mail.
Patient’s Rights & Responsibilities
I understand and acknowledge receipt of my patient rights as described in the Patient’s Rights and Responsibilities Policy.
Assignment of Benefits
I hereby authorize payment directly to the practice for the vision and medical benefits otherwise payable to me.
By my signature below, I understand that 20Twenty Eyecare will bill my insurance on my behalf to which carriers they are providers for. The office will do its best to provide as much information as possible, but I understand it is my responsibility to know my insurance benefits. I understand it is my responsibility to obtain any referrals or prior authorization as necessary, and I am responsible for any balances owed due to a lack of referral or prior authorization.
Contact Lens Policy
By my signature below, I understand that contact lens fittings are a separate service from an eye exam, and I agree to pay any fees associated with obtaining a contact lens prescription. I acknowledge that contact lens prescriptions expire annually, in compliance with Montana state law, and if I choose not to update my prescription, I will not be able to order contact lenses in the future. I acknowledge 20Twenty will provide a digital copy of my prescription that is accessible in my patient portal.
I hereby assume full responsibility for charges I incur for services from 20Twenty and agree to pay said charges in full. It is my understanding I will be responsible for any balance not paid by insurance. I acknowledge and understand that payment for all services is expected at the time of service. I acknowledge this policy is accessible on my patient portal and the practice website.
No Show, Late & Cancellation Policy
By my signature below, I understand I must give 24-hour advance notice to cancel my scheduled appointment. If advance notice is not given, I may incur a $50 fee that will be billed to my account.