SPECS Eyecare - Middletown, RI

Financial Policies

We are committed to providing you with the best possible care. If you have vision or medical insurance, we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy.

Payment for services is due at the time services are rendered unless you are a subscriber to an insurance company that we are providers for: Blue Cross & Blue Shield of RI, United Health Plan, Medicare, as well as several other insurances; or unless you have made prior arrangements with our staff. We accept cash, checks, Mastercard, Visa, and American Express. If you have a private insurance company, we will be happy to give you an itemized statement so you can submit it to your insurance company after all services have been paid for.

We must emphasize that as vision care providers, our relationship is with you, not your insurance company. While filing the insurance claim is a courtesy we extend to our patients, any claims that are denied or returned by the insurance company for reasons beyond our control will be the responsibility of the patient.

If you have any questions about the above information or any uncertainty regarding insurance coverage, please don't hesitate to ask us. We are here to help you.

Male Female Name:
Home Phone: Work Phone:
Home Address:
City: State:
Physician: Phone:
Soc. Security #: Date of Birth:
Insurance Carrier & Number:

I understand and agree that, (regardless of my insurance status), I am ultimately responsible for the balance on my account. I have read all the information above and have completed the above answers. I certify this information is true and correct to the best of my knowledge. I authorize the practice of Doctors Rispoli & Rispoli to submit any medical claims or information necessary to process the claim to my insurance company.