Patient Resources

Financing Options

We know that many of the procedures available to help you see better aren’t covered by insurance providers. We also know how important they can be to your quality of life. That is why we accept CareCredit®. CareCredit® is a patient financing program that enables patients to incrementally pay for elected procedures that are not covered by insurance. We will gladly accept CareCredit® for purchases of $200.00 and above.

To read more about CareCredit® or to fill out an application, visit www.carecredit.com.

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Forms to Download

In order to download forms, you must agree to the following terms:

PATIENT ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY

I understand and acknowledge that my insurance company pays only for covered services as they are defined in my insurance policy. I also understand that my insurance company has informed Medina Vision Centre that, per contractual agreement, I (the insured) may not be eligible to receive services if one of the following situations applies:

1.) I am not an eligible member.
2.) The services requested were denied by my insurance company as not medically appropriate or necessary.
3.) The requested service is not a covered service as defined in my insurance policy.
4.) I do not have prior authorization for requested service(s) from my insurance company. (Is a referral needed?)

I also understand that I am financially responsible for all copayments, annual deductibles, and charges for any non-covered, elective service.

Download Terms and Conditions