Your on line enrollment on this agreement constitutes authorization to provide PVCS
the personal information addressed on the front of this form (e.g., Name, Address,
Social Security Number, etc.).
Dependent Children shall remain eligible until they reach the age or status of ineligibility
for Medical coverage.
I hereby authorize Primary Vision Care Services to deduct from my bank account the
amount of required premium for the vision care coverage I have selected.
- I agree and understand that it is my responsibility to pay the full annual premium
for this plan.
- I agree to abide by the policy and procedures as specified in the plan.
This document authorizes continuous enrollment unless enrollee drops coverage during
a subsequent enrollment period.
Enrollees must use an approved PVCS panel doctor. Consult your provider list, review
our web site (www.pvcs-usa.com), or call PVCS @ 888-357-6912 to identify approved
Annual enrollment in the PVCS vision plan is for 12 consecutive months of coverage
from the original effective date. Annual enrollment requires 12 consecutive monthly
payments by automatic bank draft payments (ACH) or full payment for the contracted
year before the primary enrollee may drop any contracted coverage. Each subsequent
annual enrollment also requires 12 consecutive monthly payments.
The plan shall provide coverage the first day of the month following the month in
which the first premium payment is received. The plan shall remain continuously
in effect for the contract year and will automatically be renewed for another year
unless the Primary Enrollee notifies PVCS in writing of cancellation at least 30
days prior to the end of the contract year. If the plan is used a second time or
more during the contract year, the plan will automatically be renewed at the end
of that contract year for another full year.
The contracted premium rate schedule shall remain in effect for the 12 month period
of the contract. Thereafter, any premium rate changes shall be communicated from
the PVCS Plan Administrator to the primary enrollee and be placed in force at Plan
PVCS shall deduct by automatic bank draft payment (ACH) the monthly premium payment
from the primary enrollee’s designated bank account in advance on a monthly basis,
on the 5th day of the month prior to each month services are provided.
Services provided under this plan are being provided at a significant discount from
customary fees charged by cooperating doctors. Therefore, appointments you schedule
and are unable to keep should always be canceled at the earliest possible time to
ensure maximum courtesy in recognition of the doctor’s time and to help keep overall
plan fees as low as practical.
Any suspected or reported abuse of the PVCS Plan by the primary enrollee and/or
any enrolled dependent will be thoroughly investigated and appropriate action may
be taken, to include legal action and termination of coverage.
PVCS Plan services are not currently taxed by any government entity. However, if
a government entity establishes a tax for such services any time during the plan
period, PVCS reserves the right to add such tax charges to the cost of this offering.
Your signature on this agreement constitutes your acknowledgment of notification
and approval of such additional charges.
The panel doctor selected by the patient (primary enrollee and recorded dependents)
shall be solely responsible for the performance or non-performance of professional
services under this contract. PVCS shall not incur any liability for the actions
of the service provider (doctor), whether arising from breach of contract, negligence,
or willful misconduct, nor for any financial obligation or liability owed to the
service provider by the patient. Any incidence of non-compliance should be immediately
reported to the PVCS Plan Administrator.
An application/enrollment may be rejected or not accepted by Primary Vision Care
Services, Inc. for any reason, stated or not.