Financial Agreement For Office Centered Vision Therapy
Patient Name______
Type of Program Recommended: Level A Level B Level C ______
Projected Therapy Fees: Office Centered Vision Therapy
1. Complete Treatment Program: Therapy is normally done at a once weekly in-office 50 minute session. Patient-Therapist ratio is one-to-one. In certain cases, or during some periods of certain cases, as determined by your doctor in consultation with the therapy staff more frequent sessions may be recommended. Frequency of treatment does not affect the overall fee.
2. Treatment Lenses (Includes one frame & two sets of lenses if change is needed)
3. All progress evaluations during treatment. These are usually done at the completion of every 8 sessions of treatment.
4. Includes the first three post treatment progress evaluations, upon completion of entire therapy program. These are usually done at one month post therapy, three months after that and then six months from that time.
Total ______
************************************************************************************
All fees for the above services are the responsibility of the patient/parent/guardian. We do NOT accept assignment from insurance companies. For your convenience, we offer 3 options for payment. Cash, check, or credit card may be used for all 3 options.
1. Payment in Full: $______Minus 10% ______= $______
Payment is to be made at the time of the first treatment session.
- Pay as You Go: Your VT Fee per 50 minute therapy session and $85 per progress evaluation, which are done every 8 sessions.
- Extended Payment Plan: The case fee of ______is split up into ______equal payments of ______per month with 0% interest being charged. A credit card authorization is required for this option. Payment is due on the ______of each month. If at any time a payment is not received by the ______of the month, the credit card will be charged. If payment is not received for two months in succession, the entire remaining balance will be charged.
MC/Visa #______Exp. Date:______
Billing Address:______
IMPORTANT: No patient will be allowed to continue in the vision training program if there is failure to follow the option chosen.
Signed:______Date:______
Financial Agreement For Office Centered Vision Therapy
Patient Name______
Type of Program Recommended: Level A Level B Level C ______
Projected Therapy Fees: Office Centered Vision Therapy
1. Complete Treatment Program: Therapy is normally done at a once weekly in-office 50 minute session. Patient-Therapist ratio is one-to-one. In certain cases, or during some periods of certain cases, as determined by your doctor in consultation with the therapy staff more frequent sessions may be recommended. Frequency of treatment does not affect the overall fee.
2. All progress evaluations during treatment. These are usually done at the completion of every 8 sessions of treatment.
3. Includes the first three post treatment progress evaluations, upon completion of entire therapy program. These are usually done at one month post therapy, three months after that and then six months from that time.
Total ______
************************************************************************************
All fees for the above services are the responsibility of the patient/parent/guardian. We do NOT accept assignment from insurance companies. For your convenience, we offer 3 options for payment. Cash, check, or credit card may be used for all 3 options.
1. Payment in Full: $______Minus 10% ______= $______
Payment is to be made at the time of the first treatment session.
- Pay as You Go: Your VT Fee per 50 minute therapy session and $85 per progress evaluation, which are done every 8 sessions.
- Extended Payment Plan: The case fee of ______is split up into ______equal payments of ______per month with 0% interest being charged. A credit card authorization is required for this option. Payment is due on the ______of each month. If at any time a payment is not received by the ______of the month, the credit card will be charged. If payment is not received for two months in succession, the entire remaining balance will be charged.
MC/Visa #______Exp. Date:______
Billing Address:______
IMPORTANT: No patient will be allowed to continue in the vision training program if there is failure to follow the option chosen.
Signed:______Date:______
Financial Agreement For Office Centered Vision Therapy
Patient Name______
Type of Program Recommended: Level A Office Centered Vision Therapy Includes:
1. Complete Treatment Program: Therapy is normally done at a once weekly in-office 50 minute session. Patient-Therapist ratio is one-to-one. In certain cases, or during some periods of certain cases, as determined by your doctor in consultation with the therapy staff more frequent sessions may be recommended. Frequency of treatment does not affect the overall fee. If in the unlikely event more than 27 sessions are required, there will be a Your VT Fee charge per session.
2. Treatment Lenses (Includes one frame & two sets of lenses if change is needed)
3. All progress evaluations during treatment. These are usually done at the completion of every 8 sessions of treatment.
4. Includes the first three post treatment progress evaluations. These are usually done at one month post therapy, three months after that and then six months from that time.
Total: $Your Total
************************************************************************************
All fees for the above services are the responsibility of the patient/parent/guardian. We do NOT accept assignment from insurance companies. For your convenience, we offer 3 options for payment. Cash, check, or credit card may be used for all 3 options.
Payment in Full: $ Your Total Minus 10% (- ) = $ Discount Total
Payment is to be made at the time of the first treatment session.
- Pay as you Go: Payment is made in full at time that services are rendered at the prevailing fee schedule at the time. Current fees: 50 minutes VT Your VT Fee, Progress Exam Your PE Fee. Eye wear are as marked.
- Extended Payment Plan: The case fee of $ Your Total is split up into 12 equal payments of $____ per month with 0% interest being charged. A credit card authorization is required for this option. Payment is due on the ______of each month. If at any time a payment is not received by the ______of the month, the credit card will be charged. If payment is not received for two months in succession, the entire remaining balance will be charged.
MC/Visa #______Exp. Date:______
Billing Address:______
IMPORTANT: No patient will be allowed to continue in the vision training program if there is failure to follow the option chosen.
Signed:______Date:______
Financial Agreement For Office Centered Vision Therapy
Patient Name______
Type of Program Recommended: Level A Office Centered Vision Therapy Includes:
1. Complete Treatment Program: Therapy is normally done at a once weekly in-office 50 minute session. Patient-Therapist ratio is one-to-one. In certain cases, or during some periods of certain cases, as determined by your doctor in consultation with the therapy staff more frequent sessions may be recommended. Frequency of treatment does not affect the overall fee. If in the unlikely event more than 27 sessions are required, there will be a Your VT Fee charge per session.
2. All progress evaluations during treatment. These are usually done at the completion of every 8 sessions of treatment.
3. Includes the first three post treatment progress evaluations. These are usually done at one month post therapy, three months after that and then six months from that time.
Total: $Your Total
************************************************************************************
All fees for the above services are the responsibility of the patient/parent/guardian. We do NOT accept assignment from insurance companies. For your convenience, we offer 3 options for payment. Cash, check, or credit card may be used for all 3 options.
- Payment in Full: $ Your Total Minus 10% ( ____) = $Discounted Total
Payment is to be made at the time of the first treatment session.
- Pay as you Go: Payment is made in full at time that services are rendered at the prevailing fee schedule at the time. Current fees: 50 minutes VT Your VT Fee, Progress Exam Your PE Fee. Eye wear are as marked.
- Extended Payment Plan: The case fee of $ Your Total is split up into 12 equal payments of $____ per month with 0% interest being charged. A credit card authorization is required for this option. Payment is due on the ______of each month. If at any time a payment is not received by the ______of the month, the credit card will be charged. If payment is not received for two months in succession, the entire remaining balance will be charged.
MC/VISA #______Exp. Date:______
Billing Address:______
IMPORTANT: No patient will be allowed to continue in the vision training program if there is failure to follow the option chosen.
Signed:______Date:______
Financial Agreement For Office Centered Vision Therapy
Patient Name______
Type of Program Recommended: Level B Office Centered Vision Therapy Includes:
1. Complete Treatment Program: Therapy is normally done at a once weekly in-office 50 minute session. Patient-Therapist ratio is one-to-one. In certain cases, or during some periods of certain cases, as determined by your doctor in consultation with the therapy staff more frequent sessions may be recommended. Frequency of treatment does not affect the overall fee. If in the unlikely event more than 41 sessions are required, there will be a Your VT Fee charge per session.
2. Treatment Lenses (Includes one frame & two sets of lenses if change is needed)
3. All progress evaluations during treatment. These are usually done at the completion of every 8 sessions of treatment.
4. Includes the first three post treatment progress evaluations. These are usually done at one month post therapy, three months after that and then six months from that time.
Total: $Your Total
************************************************************************************
All fees for the above services are the responsibility of the patient/parent/guardian. We do NOT accept assignment from insurance companies. For your convenience, we offer 3 options for payment. Cash, check, or credit card may be used for all 3 options.
1. Payment in Full: $ Your Total Minus 10% (______) = $ Discounted Total
Payment is to be made at the time of the first treatment session.
2. Pay as you Go: Payment is made in full at time that services are rendered at the prevailing fee schedule at the time. Current fees: 50 minutes VT Your VT Fee, Progress Exam Your PE Fee. Eye wear are as marked.
3. Extended Payment Plan: The case fee of $ Your Total is split up into 18 equal payments of $____ per month with 0% interest being charged. A credit card authorization is required for this option. Payment is due on the ______of each month. If at any time a payment is not received by the ______of the month, the credit card will be charged. If payment is not received for two months in succession, the entire remaining balance will be charged.
MC/VISA #______Exp. Date:______
Billing Address:______
IMPORTANT: No patient will be allowed to continue in the vision training program if there is failure to follow the option chosen.
Signed:______Date:______
Financial Agreement For Office Centered Vision Therapy
Patient Name______
Type of Program Recommended: Level B Office Centered Vision Therapy Includes:
1. Complete Treatment Program: Therapy is normally done at a once weekly in-office 50 minute session. Patient-Therapist ratio is one-to-one. In certain cases, or during some periods of certain cases, as determined by your doctor in consultation with the therapy staff more frequent sessions may be recommended. Frequency of treatment does not affect the overall fee. If in the unlikely event more than 41 sessions are required, there will be a Your VT Fee charge per session.
2. All progress evaluations during treatment. These are usually done at the completion of every 8 sessions of treatment.
3. Includes the first three post treatment progress evaluations. These are usually done at one month post therapy, three months after that and then six months from that time.
Total: $Your Total ************************************************************************************
All fees for the above services are the responsibility of the patient/parent/guardian. We do NOT accept assignment from insurance companies. For your convenience, we offer 3 options for payment. Cash, check, or credit card may be used for all 3 options.
1. Payment in Full: $ Your Total Minus 10% (______) = $ Discounted Total. Payment is to be made at the time of the first treatment session.
2. Pay as you Go: Payment is made in full at time that services are rendered at the prevailing fee schedule at the time. Current fees: 50 minutes VT Your VT Fee, Progress Exam Your PE Fee. Eye wear are as marked.
- Extended Payment Plan: The case fee of $ Your Total is split up into 18 equal payments of $______per month with 0% interest being charged. A credit card authorization is required for this option. Payment is due on the ______of each month. If at any time a payment is not received by the ______of the month, the credit card will be charged. If payment is not received for two months in succession, the entire remaining balance will be charged.
MC/VISA #______Exp. Date:______
Billing Address:______
IMPORTANT: No patient will be allowed to continue in the vision training program if there is failure to follow the option chosen.
Signed:______Date:______
Financial Agreement For Office Centered Vision Therapy
Patient Name______
Type of Program Recommended: Level C Office Centered Vision Therapy Includes:
1. Complete Treatment Program: Therapy is normally done at a once weekly in-office 50 minute session. Patient-Therapist ratio is one-to-one. In certain cases, or during some periods of certain cases, as determined by your doctor in consultation with the therapy staff more frequent sessions may be recommended. Frequency of treatment does not affect the overall fee. If in the unlikely event more than 44 sessions are required, there will be a Your VT Fee charge per session.
2. Treatment Lenses (Includes one frame & two sets of lenses if change is needed)
3. All progress evaluations during treatment. These are usually done at the completion of every 8 sessions of treatment.
4. Includes the first three post treatment progress evaluations. These are usually done at one month post therapy, three months after that and then six months from that time.
Total: $Your Total
************************************************************************************
All fees for the above services are the responsibility of the patient/parent/guardian. We do NOT accept assignment from insurance companies. For your convenience, we offer 3 options for payment. Cash, check, or credit card may be used for all 3 options.
1. Payment in Full: $ Your Total Minus 10% (______) = $Discounted Total
Payment is to be made at the time of the first treatment session.
2. Pay as you Go: Payment is made in full at time that services are rendered at the prevailing fee schedule at the time. Current fees: 50 minutes VT Your VT Fee, Progress Exam Your PE Fee. Eye wear are as marked.
3. Extended Payment Plan: The case fee of $ Your Total is split up into 18 equal payments of $______per month with 0% interest being charged. A credit card authorization is required for this option. Payment is due on the ______of each month. If at any time a payment is not received by the ______of the month, the credit card will be charged. If payment is not received for two months in succession, the entire remaining balance will be charged.
MC/VISA #______Exp. Date:______
Billing Address:______
IMPORTANT: No patient will be allowed to continue in the vision training program if there is failure to follow the option chosen.
Signed:______Date:______
Financial Agreement For Office Centered Vision Therapy
Patient Name______
Type of Program Recommended: Level C Office Centered Vision Therapy Includes:
1. Complete Treatment Program: Therapy is normally done at a once weekly in-office 50 minute session. Patient-Therapist ratio is one-to-one. In certain cases, or during some periods of certain cases, as determined by your doctor in consultation with the therapy staff more frequent sessions may be recommended. Frequency of treatment does not affect the overall fee. If in the unlikely event more than 44 sessions are required, there will be a Your VT Fee charge per session.
2. All progress evaluations during treatment. These are usually done at the completion of every 8 sessions of treatment.
3. Includes the first three post treatment progress evaluations. These are usually done at one month post therapy, three months after that and then six months from that time.
Total: $Your Total
************************************************************************************
All fees for the above services are the responsibility of the patient/parent/guardian. We do NOT accept assignment from insurance companies. For your convenience, we offer 3 options for payment. Cash, check, or credit card may be used for all 3 options.
1. Payment in Full: $ Your Total Minus 10% (-_____) = $ Discounted Total
Payment is to be made at the time of the first treatment session.
2. Pay as you Go: Payment is made in full at time that services are rendered at the prevailing fee schedule at the time. Current fees: 50 minutes VT Your VT Fee, Progress Exam Your PE Fee. Eye wear are as marked.
3. Extended Payment Plan: The case fee of $ Your Total is split up into 18 equal payments of $_____ per month with 0% interest being charged. A credit card authorization is required for this option. Payment is due on the ______of each month. If at any time a payment is not received by the ______of the month, the credit card will be charged. If payment is not received for two months in succession, the entire remaining balance will be charged.
MC/VISA #______Exp. Date:______
Billing Address:______
IMPORTANT: No patient will be allowed to continue in the vision training program if there is failure to follow the option chosen.
Signed:______Date:______