Name: Lenza Eye Center
Address: 25699 SW Argyle Avenue Unit A, Wilsonville, OR, 97070, US
Telephone: +15038332662
Rating: 4.6

Step 1 of 7

Financial Policies & Billing Processes
Legal Name
D.O.B.
Month
Day
Year
Today’s Date
Month
Day
Year
Payment
Payment is due upon service. Failure to do so may result in rescheduling.

Insurance
Insurance cards must be current and presented at time of service. It is the patient’s responsibility to know the copay, deductible, and coinsurance fees.

Non-Covered Services
It is the patient's responsibility to know what insurance does and does not cover. The patient is responsible for all non-covered services.

Denied Charges
The patient is responsible for any charges denied by the insurance company.

Participating Insurances
If we are not a participating provider for a patient’s insurance plan, the patient is responsible for paying in full at time of service and filing his/her own insurance claim.

Refractions
Refraction is the process of determining if there is a need for corrective eyeglasses. It is an essential part of the eye exam in order to write a prescription for glasses or contacts and also to evaluate medical eye conditions. Most MEDICAL insurances do NOT cover this service, and it is the patient’s responsibility to pay. The fee is $60. This service IS included in a vision exam.

Returned Checks and Past Due Accounts
Returned checks will be subject to collection charges, penalties, and interest. Accounts past due after 90 days may result in collection charges, penalties, interest, or the refusal of future appointments.

Medical Insurance and Vision Plans
Some medical plans have routine vision benefits through a different carrier. We may be a participating provider with the medical insurance but not the vision plan.

Exam Authorizations and Referrals
It is the patient’s responsibility to obtain any necessary prior authorizations or referrals needed for his/her exam and services prior to the appointment.

Prior Authorization Fee
There is a $25 fee for each prior authorization for medications.

No Show Fee
There is a $30 fee for cancelling an appointment less than 24 hours from the appointment time. There is a $50 fee for cancelling surgery less than 48 hours from the surgery time.

Prescription Rechecks
There is a $60 fee for complex refraction rechecks. There is a $60 fee for any refraction rechecks after 60 days. A new exam may be required for a new prescription past that time.

Contact Lens Rechecks
There is a $30 fee for contact lens follow-ups after 30 days. A new exam and evaluation may be required for a new prescription past that time.
Patient/Guardian Signature*
Date*
Month
Day
Year
Relationship if Not Signed by Patient

Patient Rights & Responsibilities
Legal Name
D.O.B.
Day
Month
Year
Today’s Date:
Month
Day
Year
Patient Rights
- Access to Care: At our clinic, patients are assured access to essential eye care services and treatments that are medically appropriate. Ethical discussions involving the patient’s care will always include the patient, his/her family, and/or designated representatives.
- Respectful Care: Every patient is treated with respect and dignity, free from any form of discrimination based on race, color, religion, sex, national origin, disability, sexual orientation, or payment method.
- Information on Treatment: Patients are entitled to clear and comprehensive information about their eye conditions, potential treatments, and expected outcomes. Assistance like interpreters or visual aids is available for those with communication barriers.
- Refusal of Care: Patients have the right to refuse specific treatments or services within legal bounds and will be informed of any potential risks tied to their decision.
- Privacy & Confidentiality: Upholding patient privacy is a top priority. All interactions, examinations, and treatments are managed with the utmost discretion. Lenza Eye Center strictly adheres to HIPAA regulations, safeguarding the confidentiality of all health records.
Patient Responsibilities
- Communication: Patients are encouraged to be open and accurate in sharing information about their eye health, vision issues, and any other relevant medical history.
- Respecting Others: Mutual respect ensures a harmonious environment. Patients are expected to be considerate of other patients, clinic staff, and the facility. Disrespectful behavior will not be tolerated.
- Participation: It is essential for patients to comply with prescribed treatments, attend follow-up appointments, and collaborate with our eye care professionals.
- Financial Obligation: Patients are expected to provide accurate billing details and address any financial commitments related to their care.
Physician Investment

Please be informed that your physician may have a financial interest or ownership in Lenza Eye Center.

Patient Complaints and Grievances

Lenza Eye Center values feedback. If you have any concerns or suggestions, please do not hesitate to let us know. All patients have the right to voice concerns or complaints about the care they receive. Unresolved issues can be directed to the Clinic Administrator.
Patient/Guardian Signature*
Date*
Month
Day
Year
Relationship if Not Signed by Patient

Glasses & Content Lens Policies
Legal Name
Date
Day
Month
Year
Today’s Date
Day
Month
Year
- Cancellation of Glasses Order: Orders may be cancelled for a refund only if the lab has not yet started processing the lenses.
- Frame Restyling:
  - Restyling must be within 60 days of the original order date.
  - There is a $100 restocking fee.
  - The patient is responsible for the difference in cost of the new frame in addition to the restocking fee.
  - A $20 warranty fee will be applied to make new lenses.
- Non-Adapt to Glasses Lens Styles:
  - Lenses must be returned within 60 days of the original order date.
  - Progressive lenses can be exchanged for trifocal, bifocal, or single vision lenses at no cost.
  - All other lenses can be switched to a single vision lens at no cost.
  - A refund will not be given for the difference in cost between the original and new lenses.
  - Lenses can be upgraded to a higher level lens type. Patients will only be charged the difference.
- Lens Option Changes: A $20 warranty fee will be applied to make new lenses if the patient chooses to change any lens options.
- Glasses Lens Warranty: A $20 warranty fee will be applied to make new lenses if original lenses become scratched or damaged.
- Broken Frames Caused by a Manufacturer’s Defect:
  - Current frames have a one year warranty for manufacturer’s defects.
  - Discount and sale frames are not covered under warranty.
  - Damage from patient mishap is not covered under warranty.
- Doctor Glasses Prescription Changes:
  - Lenses can be remade with a new prescription at no cost one time only within 60 days of purchase.
  - If there is a prescription change after 60 days, a $20 warranty fee will be applied.
  - If the patient would like more than one remake, a 50% discount will be given on the new lenses.
- Contact Lens Returns and Exchanges:
  - Soft contact lenses shipped to our office and picked up by the patient are eligible for return within 90 days of the order date.
  - Soft contact lenses shipped to the patient’s home are eligible for return within one year of the ship date.
  - Gas permeable contact lenses are eligible for exchange within 120 days of the order date.
  - Gas permeable contact lenses cannot be returned for a refund.
Patient/Guardian Signature:*
Date*
Month
Day
Year
Relationship if Not Signed by Patient

Intake Form

Step 1 of 7

Patient Information

Patient Medical History

Have you received the following vaccines?

Please indicate your use of the following:

Please check all family eye conditions:

Please check all family health conditions:

Financial Policies & Billing Processes

Patient Rights & Responsibilities

Patient Rights

Patient Responsibilities

Physician Investment

Patient Complaints and Grievances

Glasses & Content Lens Policies

Authorization to Receive/Release Health Information

Due to the HIPAA compliance privacy laws of the federal government, it is mandatory that we ask you to review and answer the following questions.

Notice of Privacy Practices (HIPAA)

Wilsonville Office

Newberg Office

Contact Us Today