** Please print, complete, and return by mail to our Mount Vernon address: 2100 Little Mountain Lane, Mount Vernon, WA 98274.
LASIK Consent Form
Photorefractive Keratectomy (PRK) Consent Form
We’re happy to bill your primary insurance company for you. We can get an estimate of your benefits so you’ll have a better idea of what your insurance may cover. We can also provide you the necessary information so that you can bill any secondary coverage you may have.
When we quote you benefits, this is only an estimate of your coverage and not a guarantee of payment. We relay the information given to us by your insurance company. This information is not always accurate. Consult the benefits information that you received from your employer for more detailed information. When your insurance company processes the claim, they may pay differently than what they initially stated. You are ultimately responsible for any charges.
Here are just a few of the plans we can bill for you:
||Regence||Check your benefits on-line|
||Premera||Check your benefits on-line|
||Vision Service Plan (VSP)||Check your benefits on-line|
||First Choice Network||Call the number on the back of your card for benefit information|
||Uniform Medical Plan||Check your benefits on-line|
||LifeWise Health Plan||Check your benefits on-line|
||GroupHealth Cooperative||Check your benefits on-line|
|Medicare||Covers 80% of the medical portion of the exam after deductible.|
Acceptable Forms of Payment and Payment Options
Here at Cascadia Eye and Eye Associates Surgery Center, financial consideration should not be an obstacle in obtaining the eye care you deserve. Our goal is to make eye care, including refractive surgery and other higher priced eye care needs, affordable for any budget. You may choose any of the following payment options:
Cash or Check — If we will not be billing insurance or you are paying for a “non-covered” service or product we offer a generous pay-at-the-time-of-service discount for your exams and refractive surgery. Your balance must be paid at the time of service to qualify for this discount.
Credit Card — We accept Visa, MasterCard and American Express.
Financing – We work with Care Credit financial corporation to offer 6 or 12 month interest-free payment periods. If you choose to extend your payment period beyond the initial 12 months, significant interest fees will apply.