HIPAA Policy Form Read through our HIPAA Policy Form here. Financial Policy We are committed to providing you with a great customer experience and are happy to verify insurance eligibility and benefits. However, this is never a guarantee of benefits as some insurance companies arbitrarily select certain services that they will not cover and/or must be medically necessary. It is your responsibility to understand the scope and limitations of your insurance policy and you are financially responsible for all charges rendered whether or not paid by your insurance. For medical care, if you have not met your deductible, we will collect half of your balance at the time of service. You will receive a bill for the balance after your insurance processes your claim unless other arrangements have been made. Any non-covered services or copays are due at the time of service. Contact lens exam services are not covered by most insurance. All contact lens follow ups must be completed within 90 days or a new exam will be necessary.* I acknowledge that I have had the opportunity to read over both the HIPAA and financial policies of Blink Eyecare and agree to their terms. Signature*Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NameThis field is for validation purposes and should be left unchanged.