Lumen Membership Plan Enrollment Agreement

Lumen Eye Care

76 Northeastern Blvd, Unit 23A | Phone: 603-598-1620 |

Effective Date: August 2026

1. Introduction

Lumen Eye Care is an independent eye care practice located at 76 Northeastern Blvd, Unit 23A. All enrollment, billing, and payment processing for the Lumen Membership Plan is handled entirely in-house through the practice’s own electronic health record (EHR) system with integrated merchant services. No outside third-party software is used to enroll patients, process payments, or manage plan accounts.

2. Purpose of the Plan

The Lumen Membership Plan is not insurance, is not a line of credit, and is not a discount program. It is simply a structured payment arrangement offered directly by the practice. The Lumen Membership Plan is an in-house payment program that allows eligible patients to pay off an outstanding bill balance using a credit card on a monthly recurring basis.

3. Plan Terms

The Lumen Membership Plan includes two plan types: the Eyewear Payment Plan and the Medical Services Plan. The following terms apply to the Eyewear Payment Plan:

Eyewear Payment Plan:
- Payments are automatically charged to the credit card placed on file on the scheduled payment dates.
- The remaining balance is paid off through three (3), six (6), or twelve (12) additional monthly payments, according to the schedule the patient selects at enrollment.
- Standard plans require a down payment of fifty percent (50%) of the total balance at enrollment.
- Plans involving contact lens materials require a down payment of seventy-five percent (75%) of the total balance at enrollment.
Medical Services Plan:
- The Medical Services Plan includes one (1) annual comprehensive eye exam with retinal imaging and glasses prescription AND two (2) specialty office visits per year (such as dry eye, glaucoma and its relevant scans, age-related macular degeneration (AMD) and its relevant scans, and red eye visits).
- The Medical Services Plan is billed monthly only; no down payment or deposit is required.
- Unused specialty visits do not roll over and carry no cash value.

4. Payment Authorization

By enrolling in the Lumen Membership Plan, the patient authorizes Lumen Eye Care to charge the credit card placed on file for the down payment and for each scheduled recurring payment. All card data is handled through the PCI DSS-compliant merchant services integrated into the practice’s EHR system. The patient is responsible for keeping the credit card on file current and valid. If a payment is declined, Lumen Eye Care will attempt to retry the charge and will contact the patient from the office; repeated declined payments may result in suspension of the plan, at which point the remaining account balance will become due. The patient may update the card on file or pay off the remaining balance early at any time.

5. Eligibility and Enrollment Process

Enrollment in the Lumen Membership Plan is available to eligible patients with an outstanding balance at Lumen Eye Care. To enroll, the patient completes an enrollment form, provides valid identification and the credit card to be placed on file. Office staff will verify the outstanding balance and present the available payment schedule options to the patient. Enrollment is complete only when the enrollment form is signed and the down payment is successfully processed.

6. Cancellation and Changes

Patients may contact the office at any time to discuss their payment schedule or request changes. Missed payments may result in suspension of the plan as described in Section 4. Except as required by law, down payments are non-refundable once the plan is enrolled.

7. Privacy

Lumen Eye Care is committed to protecting patient information. All personal, financial, and health information collected under this agreement is handled in accordance with the Lumen Eye Care Privacy Policy and the practice’s Notice of Privacy Practices. Questions about privacy or this agreement may be directed to: Lumen Eye Care, 76 Northeastern Blvd, Unit 23A, Phone: 603-598-1620, Email: reception@lumeneyenh.com

8. Terms and Conditions

Term and Cancellation: The plan term runs from the enrollment date for the period corresponding to the selected plan: the Medical Services Plan is a 12-month term; Eyewear Payment Plans run until the selected payment schedule is completed (2, 4, or 6 monthly payments). There is no auto-renewal; the plan does not automatically renew at the end of the term. A member may cancel the plan at any time by contacting the office; however, any remaining unpaid balance must be paid in full, using another payment method if necessary, at the time of cancellation.
Late or Missed Payments: If a scheduled payment is declined, returned, or missed, the practice may suspend plan benefits and included services until the balance is brought current. A late or missed payment may incur a penalty of 10% of the outstanding balance (or a $10 minimum, whichever is greater). Any outstanding balance must be paid in full before any other services or materials are rendered to the member.
Chargebacks: The member agrees not to initiate chargebacks, payment disputes, or reversals with their card issuer for authorized plan fees. If a chargeback occurs, the practice may terminate enrollment, require reimbursement of the disputed amount plus any chargeback fees and related costs, and refer the account to a collections agency.
Refunds: Down payments are non-refundable except as required by law. Medical Services Plan monthly fees are non-refundable once the billing month has begun.
Limitation of Liability: The practice's liability under this agreement is limited to the amounts actually paid by the member under the plan. The practice is not liable for indirect, incidental, or consequential damages.
Dispute Resolution and Governing Law: Disputes arising under this agreement should first be addressed directly with the practice. If unresolved, disputes shall be resolved in accordance with the laws of the State of New Hampshire, and the parties consent to the jurisdiction of the courts located in New Hampshire.
No Combination with Insurance or Other Offers: The plan may not be combined with vision insurance, Medicare, other government programs, discount plans, or other in-office promotions or offers that apply to the same included benefits.
Account Standing for All Participants: The account holder must be current on all payments for all plan participants on the account for any plan participant to receive included services or applicable discounts.
Account Holder Responsibility: The account holder must be 18 years or older, is responsible for all fees incurred by every plan participant enrolled on the account (e.g., spouse, dependents, or other family members), and is responsible for keeping account and payment information accurate and current.
Conditions Discovered During Treatment: If a vision or health condition requiring further treatment is discovered during the course of an examination or treatment (e.g., cataracts or glaucoma treatment or surgery), the costs of that further treatment are the patient's responsibility and are not covered by the plan.
Separate Office Fees: Late fees, missed-appointment fees, and other standard office policies apply separately and are not covered by the plan.
Non-Transferability: Enrollment and membership benefits are personal to the account holder and each plan participant and may not be assigned, transferred, or delegated to any other person.
Changes to Terms and Severability: Lumen Eye Care may modify these terms with reasonable prior notice; changes apply prospectively only and do not affect amounts already owed. If any provision is held invalid or unenforceable, the remaining provisions remain in full force and effect