Quotation Estimate Optometrist in United States New York City –Free Word Template Download with AI

Terms & Conditions of This Quotation Estimate

1. This Quotation Estimate is valid for thirty (30) calendar days from the date of issuance. Pricing for corrective products, including lenses and frames, is subject to change based on manufacturer availability and exchange rate fluctuations.
2. All optometric services described herein will be performed by Dr. Eleanor Whitfield, O.D., a licensed Optometrist in the State of New York, United States, or by a credentialed associate under her direct supervision at our New York City practice.
3. The estimated insurance adjustment is based on current Aetna Vision Plan benefits as of the date of this Quotation Estimate. Actual reimbursement may vary depending on pre-authorization status, deductible fulfillment, and plan-specific coverage limits. The patient is responsible for any difference between the estimated and actual insurance adjustment.
4. New York City sales tax of 8.875% applies to all tangible corrective products (lenses, frames, and accessories). Diagnostic and professional optometric services are exempt from sales tax under New York State Tax Law Section 1105(c)(1).
5. Payment is due at the time of service or product dispensing. We accept all major credit cards, HSA/FSA cards, and personal checks. A 1.5% surcharge applies to checks returned for insufficient funds.
6. This Quotation Estimate does not constitute a binding contract. Final charges may be adjusted if additional diagnostic procedures are deemed medically necessary during the examination. The patient will be informed of any additional costs prior to their authorization.
7. All patient records, diagnostic images, and prescription data are maintained in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and New York State Public Health Law Article 27-F.
8. Should the patient wish to cancel or reschedule, a 24-hour notice is required. Cancellations within 24 hours of the scheduled appointment will incur a $50.00 administrative fee.
9. This Quotation Estimate is prepared exclusively for the named client and may not be transferred to a third party without written consent from Manhattan Vision & Optometry Center.