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Patient Responsibility and Office Policies



We have written this policy to help you navigate our office to allow us to provide balanced customer service for you and our other patients.

Our core values: We believe healthcare is a calling and that we are called to provide excellent care for the eyes of the Cincinnati area. We desire to provide great value to all of our patients. In our mission to prevent blindness and optimize eye health: we prioritize quality of care over being the least expensive provider of an eye exam.

Appointments: We see patients by appointment only. Same day appointments are usually available for urgent or sudden illness. We do everything in our power to see a patient who arrives in our office needing to be seen. Patients given same day appointments may expect increased waiting times in the office.

After Hours and Emergencies: For a serious emergency, go to the nearest emergency room or call 911 right away. Many eye emergencies can cause permanent vision loss. If you are in pain, or if your vision is decreasing suddenly: you are having an emergency that needs treatment to prevent vision loss. People who have recently had surgery on the eyes should be especially vigilant, and notify the emergency room physician to discuss the case with the ophthalmologist on call.

Cancellations: Please call within 24 hours if you are unable to keep your scheduled appointment. This allows us to provide that time slot to another patient.

No-shows and Late Arrivals: When you schedule your appointment with us, we set aside enough time to provide you with the highest quality of care. Should you need to cancel or reschedule an appointment please contact our office as soon as possible, no later than 24 hours prior to your scheduled appointment. No show/late fees are charged to the patient, not your insurance company. Any balances on a patient’s account must be paid prior to booking another appointment or before any service is provided.​

Late Arrival Definition: If a patient is 10 minutes late or more for an appointment, the appointment needs to be rescheduled and fees are below. All patients are encouraged to arrive at the office at least 10 minutes prior to the scheduled appointment to register and complete any required paperwork.

No Show / Late Policy: Appointments should be canceled by one (1) business day prior to your scheduled appointment (or by 12 pm on Saturday for appointments taking place the following Monday).

New Patient No Show/Late Fees: Any new patient who fails to show for their initial visit will be dismissed from the practice. The new patient may pay the no show / late reinstatement fee of $60, put a payment method on file and reschedule at the office’s discretion.

Existing Patient Unexcused No Show/Late Fees:

1st No Show/Late = Courtesy reminder

2nd No Show/Late = $40.00 fee

3rd No Show/Latee = $60.00 AND potential dismissal from Madeira Optical for additional infractions.

Appointment Times And Arrival Times: We ask patients to arrive at the office 10 minutes prior to their scheduled appointment. We provide electronic intake forms, but we also anticipate the need to answer questions, fill out miscellaneous paperwork, insurance authorizations and referrals before going to the exam room. There is some natural variation in the time it takes to provide any given service. Our patients will take different amounts of time to complete tasks, and have different and sometimes unanticipated health care needs. We strive to transit patients through our office quickly and efficiently. Please accept our apology in advance because we cannot always meet that benchmark.

Running on Time: We respect that your schedule is busy and that your time is valuable. Please let us know if you have waited more than 10 minutes so we can be sure you are properly checked in. Remember that we are running several different schedules. If someone who arrives after you is called before you, they might be here for a test or seeing a different provider.

Eye Exams: Our principal service is providing eye exams. Physicians have no ability to diagnose an eye problem on the phone. We cannot make any diagnosis or recommendation based on a conversation in the waiting room. We certainly cannot treat any condition you do not bring to our attention by telling us all of your symptoms and allowing us to examine you.

Please do not ask the doctor to speak to you on the telephone or in the waiting room before an exam. We welcome the opportunity to answer all of your medical questions in the exam room, after the exam. If you have an urgent need to speak with the doctor, prepare yourself for an eye exam and come on in.

Please help the doctor provide great care by participating fully in the pre-exam work up with our excellent ophthalmic technicians. If we are unable to collect all of the information we need, we cannot fully answer your questions.

Please consider bringing a trusted friend or family member into the exam room with you. It is very helpful to have a second pair of eyes and ears with you to help remember and fully understand your conversation with the doctor.

Refractions: Refraction is the process of determining the eye’s refractive error, or need for corrective lenses. The refraction is needed for a patient experiencing blurred vision, or if we detect a decrease in visual acuity on the eye chart. The refraction allows us to determine if decreased vision is due to need for glasses, or if a medical problem is to blame. A refraction is needed if you are considering cataract surgery, or if you want a prescription for eyeglasses.

The refraction is an essential part of a complete eye exam, however Medicare and most medical insurance do not cover it. The refraction fee is in addition to any copay or deductible set by your insurance carrier. The refraction fee is due at the time service is provided. If you believe your insurance will pay, we will happily submit the charge to them. However, we cannot release a prescription for eyeglasses unless the account balance is paid.

Eyeglass Prescriptions: Please let us know before your exam if you want a new prescription for eyeglasses. The refraction is most accurate if performed before we disrupt your tear film with eye drops and pressure checks, and before we dazzle your vision with bright lights. This helps us provide a more accurate prescription for glasses.

Contact Lens Prescriptions: Please let us know if you want a prescription for contact lenses before you schedule your exam. Only certain members of our team perform contact lens exams, so plan ahead.

The contact lens prescription is more complex than an eyeglass prescription and is a separate billable service in addition to the refraction. The contact lens fitting fee is in addition to any copay or deductible set by your insurance carrier. Contact lenses are fit by trying different lenses on the eye and assessing vision and comfort. Sometimes multiple visits are needed.

Contact Lenses: Contact lenses constantly disrupt the corneal epithelium, putting the eye at risk for complications that can profoundly reduce sight or cause loss of the eye. Contact lens wearers agree to:

  • Never sleep in their contact lenses.
  • Remove and clean contact lenses every day according to instructions.
  • Dispose of contact lenses at appropriate intervals, or if they are damaged or become uncomfortable.
  • Come for an exam immediately if the eye becomes red or painful, or if the vision decreases.

Dilated Eye Exams: A comprehensive eye examination involves using eyedrops to dilate the pupil. Dilating the pupil makes it possible to view a much wider area of the retina, allowing us to detect diseases that are the leading cause of blindness, including cataract, diabetic retinopathy, macular degeneration and glaucoma. The National Institutes of Health recommends a dilated eye exam periodically for all people, and every year for people over the age of 60. People with conditions like diabetes, glaucoma and macular degeneration should also have an annual dilated exam. In general, we require a dilated exam for all new patients. We also require a dilated exam before we schedule any procedure or surgery.

Eyedrops that dilate the eyes will make the vision blurry, especially for reading. The eyes will also be sensitive to light. The effect of the drops lasts for four to six hours. Please bring a driver or arrange alternative transportation for your eye exam to reduce the risk of accidents. If dilating the eyes would prevent you from having safe transportation home, please notify us so we can reschedule your exam.

Prescriptions and Refills:

  • The best time to get a prescription refill is at your appointment.
  • In general prescriptions need to be authorized by the doctor, who is likely in an exam room, and has other patients who are waiting.
  • We strive to process called, faxed or electronic prescription refill requests quickly.
  • If you need to call for refills, please don’t wait until you run out.
  • We do not call in new prescriptions without an exam, but we will happily see you.
  • We do not call in prescriptions after hours, but we will try to get a sooner appointment if you need help.
  • We do not prescribe narcotics for chronic use, or call in prescriptions for narcotics.
  • Please don’t wait at the pharmacy or optical shop for your doctor to call.

Equal Opportunity: Madeira Optical affords equal employment opportunity to all individuals regardless of race, creed, color, religion, gender, national origin, ancestry, age, marital status, veteran status, disability, medical condition, gender identity or sexual orientation. In addition it is the policy of Madeira Optical to provide excellent medical and refractive eyecare to patients, regardless of race, creed, color, religion, gender, national origin, ancestry, age, marital status, veteran status, disability, medical condition, gender identity or sexual orientation.

Limitation of physician-patient relationship: Madeira Optical provides refractive and medical eye care services. We strive to provide comprehensive eye care, but may at times refer a patient to specialists outside our practice for certain eye conditions.

As a patient of Madeira Optical, you agree that the physician-patient relationship with Madeira Optical physicians is limited to conditions that they treat. Patients with systemic medical conditions agree to seek care from their Family Practice or Internal Medicine physician for the care of those problems. This includes systemic medical conditions that affect the eyes or vision. Madeira Optical may at its discretion help arrange referrals. You agree to take responsibility for arranging any care provided elsewhere. It is the patient’s obligation to establish their own relationship with appropriate physicians.

As a patient of Madeira Optical, you agree Madeira Optical provides care by appointment only, during limited hours and location. You agree that information posted on this website, which may change, is the only notice we will provide to you regarding office hours and locations. Madeira Optical’s physicians may at their discretion make arrangements for provision of emergency care with physicians outside our practice.

As a patient of Madeira Optical, you agree the physician-patient relationship is limited in duration. You agree that the physician-patient relationship is terminated by mutual agreement three months following the most recent exam. Termination of the physician patient relationship concludes Madeira Optical’s obligation to provide medical care, but not Madeira Optical’s obligation to maintain medical records, the patient’s obligation to pay for medical care previously received, or the patient’s obligation to pay for administrative expenses incurred after the conclusion of the physician-patient relationship. You agree that this is the only notice we will provide regarding termination of the physician-patient relationship. Patients in good standing may and typically do reestablish care at Madeira Optical annually or at any time by scheduling an appointment.

Dismissal: If you are “dismissed” from the practice, it means you can no longer schedule appointments, get medication refills, or consider us to be your doctor. You must find a doctor in another practice.

Common Reasons for Dismissal:

  • Failure to keep appointments, frequent no-shows
  • Noncompliance, which means you won’t follow physician instructions about an important health issue.
  • Abusive or inappropriate behavior with staff or physicians.
  • Failure to pay your bill.
  • Loss of therapeutic relationship.

Physicians and patients require a therapeutic relationship to provide quality care. Negative or positive emotions experienced by the physician or patient may interfere with care, may cloud medical judgement, and could prevent a patient from receiving the best of care.

Friendship, family or business relationships, romantic feelings, anger, disappointment, disagreement and distraction can all cause loss of a therapeutic relationship. A patient who is considering any administrative or legal action against a physician has likely lost their therapeutic relationship with that physician, and would best be served by seeing a different provider. Avoidance of transference and countertransference that interfere with medical care is an important principle of Medical Ethics.

As a patient of Madeira Optical, you agree that dismissal for loss of therapeutic relationship is not intended to be disrespectful, demeaning, insulting or humiliating. You agree dismissal does not constitute any form of punishment or retaliation. Physicians who dismiss patients for loss of therapeutic relationship do so for the benefit of the patient, so the patient may receive unbiased care elsewhere.

Dismissal Process: We will send a letter to your last known address notifying you that you are being dismissed. If you have a medical emergency within 30 days of the date on this letter and cannot acquire care, we will see you as our schedule allows or help arrange for care. After that date, you must find another doctor. We will forward a copy of your medical record to your new doctor after you let us know who it is and sign a release form


  • We accept cash, checks, Visa, Mastercard, Discover, American Express and Apple Pay.
  • Most eye care materials and services are FSA/HSA approved. Please check your plan.
  • We do not provide extended credit after your third-party explanation of benefits is processed as that takes 30-60 days or more. All patients are required to keep a payment on file for third-party balance transfers and payments are processed upon determination.

Promise to Pay: You promise to pay in full for all:

  • Services we provide to you,
  • Items we provide to you including eyeglasses and contact lenses,
  • Credit we extend to you for the purpose of billing your insurance,
  • Interest charges and other fees or charges such as returned check and late payment fees plus,
  • Collection costs and attorney fees as allowed by law.

No Insurance: We happily see people who do not have insurance. We may at our discretion offer a prompt pay discount for people who pay in full at the time of service. If you are unable to pay in full at the time of service, please inquire about payment arrangements.

Medical Insurance: We accept most forms of major medical insurance, Medicare, and Medicaid. You as a patient accept final responsibility to pay for all services performed, including non-covered charges, deductibles, and copayments or coinsurance. In most cases, medical insurance plans do not cover refraction fees, contact lens fitting fees, or optical materials.

Vision Plans: We accept many forms of vision plans. Vision plans may cover a portion of refractive eye exams for glasses, contact lenses, and optical supplies. You, as a patient, accept final responsibility to pay for all services performed, including non-covered charges, deductibles, and copayments. In most cases Vision Plans do not cover exams for medical problems, such as visual problems that cannot be corrected with eyeglasses, painful conditions, red or irritated eyes, or exams related to medical conditions like diabetes. Our optometrists are Medical Doctors who will bill you for medical services provided. By providing a copy of your medical insurance, we can reduce the likelihood that you receive an unwanted bill.

Verification of Benefits: As a courtesy to you, we may verify insurance benefits before your visit and may assist in obtaining necessary referrals and authorizations. You as a patient accept final responsibility for knowing your insurance benefits, knowing whether our physician is on your plan, and obtaining referrals and authorizations needed for payment. You as a patient accept final responsibility to pay for all services performed, including non-covered charges, deductibles, and copayments.

Filing Insurance Forms and Accepting Assignment: As a courtesy to you, we will file primary insurance forms in our office for plans we accept. In order to do this, we require accurate information from you. Please bring your current insurance card and photo ID to each visit.

At the time of service, you will be responsible for all known fees that are not covered by your insurance, including co-insurance, deductibles, and non-covered services or items received. We strive to be as accurate as possible in calculating your responsibility, but with so many variations in policies and fee schedules we are not always exact. Your payment method on file may be used to pay for balances and you may receive a statement from our office for any balance due.

Auto Accident/Worker’s Comp: If your injury is the result of an auto accident or a workplace injury, you are required to pay for services and then collect from the carrier. We will not file your insurance, but will provide you with a receipt to do so.

Liability Injury: If your injury is a result from another party’s negligence, you are required to pay for and then collect from the responsible party. We will not file your insurance, but will provide you with a receipt, to do so.

Return Checks: There will be a charge for any check returned by your bank for any reason. The returned check fee is $40.00

Returns: We want you to love your eyewear. Eyeglasses are complex custom medical devices. Our professional opticians work closely with patients to make sure we deliver quality eyewear the first time and remedy any concerns quickly. We will work with patients to make sure you sure you are happy with the eyewear you select, including manufacturer’s waranties, adjustments and refits at the licensed optician’s discretion.

  • In the event that a patient is not satisfied with the visual acuity obtained with the prescription lenses, we will conduct a review of the lens prescription, adjustment of the glasses and, as necessary, schedule a short prescription check in our office.
  • If you are not completely satisfied with your purchase, you may cancel before the job is processed or complete for a full refund PRIOR to lab processing. We work to process your glasses quickly for you. If the job process has started there is a 25% cancellation fee passed on from lab charges that have been accrued on the order. A 25% restocking fee will apply for the frames.
  • Often, we must send your eyewear to your managed care third-party for lab processing. Per your vision plan agreement, they are responsible for producing your eyewear. We do our best to work closely with the lab your third-party owns or utlizes. We re-inspect every job produced by third-party provider labs. If your managed care provider’s lab work fails accepted industry quality standards, we will reject your glasses on your behalf and re-order them at no charge to you. This will delay the processing. Delays and communication challenges from managed care companies and/or lab order breakage are not our responsibility.
  • We are not responsible for breakages of patient owned frame. We will adjust them and repair them at your risk. However, in the event of a breakage, you will be given a 20% courtesy discount off the retail value of another frame if you wish to replace it at our office.
  • Lenses are not scratch proof. Most patients choose lenses with a manufacturer’s scratch waranty. If you upgrade to a lens which are scratch resistant, then you may be eligble for a mnufacturer’s one-time replacement.
  • What is not covered: Eyewear furnished by others, lost or stolen glasses, any damages to the frames due to normal wear and tear, abuse, unauthorized repairs, introduction of any foreign objects to the product and unauthorized product modifications or alterations such as but not limited to: any use of glue (i.e.super glue or hot glue), welding, soldering or tape.

​​​​​​​Medical Records: We will provide you a copy of your medical records upon request and for a fee. You will need to sign a letter of release prior to having them copied. Please allow up to 20 days for this request to be processed.

Limited Ability for Insurance Appeals: If your insurance does not pay for a service, we may help you appeal if we believe you have a good case. Our staff cannot submit multiple appeals on your behalf or submit appeals that we do not believe are likely to be successful.

Statements: If you receive a bill from us, it is because your third-party explanation of benefits mailed to you has indicated that the balance is your responsibility. A bill may come several months after the date of service, depending on how long it takes for your insurance to make a final determination. Please contact your insurance company first if you believe there is a problem. If you cannot pay your entire bill, please call to make payment arrangements. Statements may be processed with payment on file per the patient financial agreement.

Collections: You agree to pay any balance due, in full, within 30 days of the statement mailing date. Accounts that are not paid within 30 days begin our in-house collection process. Late payments may incur a fee of up to $20 per month. If your balance becomes 65 days old, your doctor will be notified, and you may be subject to dismissal from the practice. You agree to pay any collections costs or legal fees incurred.

Your Benefits: Your visit may be covered by a vision plan or medical insurance depending on the chief compliant. Vision plans generally cover healthcare services directly related to vision (how you see) and manage the costs associated with routine eye care. These are typically defined benefit plans with limited benefits and not insurance.

Examples of what vision plans might cover in full or part include:

  • Annual wellness eye exams
  • Prescription eyewear, including contacts and glasses (frames and lenses)
  • Corrective surgery, such as LASIK or to treat cataracts
  • Unlike regular health insurance plans, which have a system of deductibles and co-pays built in and generally offer unlimited benefits after deductibles are met, vision plans are wellness benefit plans, meaning you get certain coverage and discounts for paying a monthly or annual premium.

Health insurance generally covers eye health in relation to a medical condition. For instance, if you need eye care because of cataracts, complications from diabetes, or in relation to diagnosed high blood pressure, then your health insurance will usually cover that medical eye care.

In addition to covering eye care for medical conditions, health insurance will typically cover care if you experience an eye injury or develop an eye disease.

Insurance Card Required At Time of Service: If you do not provide your insurance card or proof of insurance, payment-in-full is appreciated and expected at the time of service. Incorrect or incomplete information may lead to a claim denial, so please verify all of your information that we have on file. We will resubmit corrections one time as a courtesy to you. After the second submission, the balance is due in full and you are free to submit additional claims directly with your insurer.

Billing Questions: We always bill usual & customary fees. Our office is not a party to your contract with your insurer and we do not make claims determinations. Please contact your third-party with coverage questions. If you have questions about what was billed during your visit, please refer to the invoice provided on the day of service or contact our office.

Payment Guarantee: We cannot extend additional credit to patients who have insurance transfer balances due. We will ask you to keep a credit/debit card on file in our secure online system for services billed to your insurance. Once the claim has been processed, your card will be charged for any remaining patient responsibility as deemed by your contract with your insurer. These amounts can be found on your insurer’s EOB (Explanation of Benefits) mailed/emailed to you after your claim is processed. We are a medical practice focused on high quality and cost-efficient patient care and we do not have a finance department and do not extend credit to individuals.

As guarantor, if you don’t wish to keep a card on file, you may be required to pay in full for your visit and be refunded the difference of your insurance payment. Your contract with your insurer states that you are the responsible party. If the third-party decides not to cover a service or material for ANY reason, you are responsible for the balance for services provided.

Co-pays: After your insurance is billed, your card on file will be charged for any unpaid copays or coinsurance amounts on the insurer’s explanation of payment.

Deductibles: Likewise, after your insurance is billed, your card on file will be charged for unmet deductible amounts listed on your insurer’s explanation of payment.

Errors: If you ordered a product or service and payment was not collected at the time or service or when the product is ordered per our financial responsibility policy, we will process your payment method on file and send you the receipt upon discovery of that error.

Changes to this Notice: We reserve the right to change this Notice at any time, along with our policies and procedures. We reserve the right to make the revised or changed Notice effective for existing patients, and patients agree to office polices as reasonably changed. We will post a copy of the current notice, along with an announcement that changes have been made, as applicable, in our office. When changes have been made to the Notice, you may obtain a revised copy by sending a letter to the Practice Administrator at the address listed below or by asking the office receptionist for a current copy of the Notice.

Complaints: If you believe that your rights as described in this Notice have been violated, or if you have questions, comments or concerns you may file a complaint with the Practice at the following address:

Madeira Optical

Attn: Practice Administrator

6725 Miami Ave., Suite 101

Cincinnati, OH 45243

To file a complaint, you may either call or send a written letter. The Practice will not retaliate against any individual who files a complaint. In addition, if you have any questions about this Notice, please contact the Practice’s Administrator at the address listed above.

Revised September 22, 2022