When it comes to
services and payments, no one likes surprises! For this reason, we would like to
explain our office payment policies, and clarify how you wish to pay for y=
our
services in our office. After reading this policy, please check one of the
following payment options below (continued on the back), and hand this pap=
er to
our receptionist. By checkin=
g this
option and signing this form on the back, you agree to follow this option =
as
described. If you have any
questions, please contact our office.&nbs=
p;
Thank You.
A. PAYMENT IS DUE AT THE TIME OF SER=
VICE OR
RECEIVING MATERIALS.
If other arrangements are necessary, they must be made PRIOR to receiving services.=
B. INSURANCE PATIENTS - Due to the increasing complexity and variability of the many
different insurance plans today, and because more and more of the plans
reimburse the patient directly, we are now asking our patients to pay his =
or
her entire bill directly to our office.&n=
bsp;
If the insurance payment comes to our office, we will promptly refu=
nd
the patient.
If y=
ou would
like for our office to file your insurance claim for you, you must be sure=
to
bring an insurance form with you to your examination appointment. Be sure you have completed your s=
ection
of the form before your appointment date, and we will complete our part.
C. CONTACT LENS PATIENTS - At least 50 % of the total fees are due when=
your
contacts are picked up. The =
remainder of the fees are due at your first follow-up=
check.
D. MEDICARE PATIENTS - You must bring your Medicare card to your first appointment. Medicare will pay part of t=
he
examination fee if the symptoms or diagnosis warrants. The other part of the examination=
fee is
your responsibility. We ask =
that
you pay our office at the time your services are provided for the amount w=
e do
not expect Medicare to pay.
Medicare will send YOU a statement indicating the amount that was p=
aid
to us and the services they reimbursed.&n=
bsp;
They will subtract out any Medicare deductibles you have not met fo=
r the
current year.
We are not required t=
o wait
for the secondary insurance carrier to pay before billing you directly for=
the
unpaid balance. If you have =
had
cataract surgery, then one pair of glasses are =
covered
after each surgery.
E. MEDICAID PATIENTS - You MUST bring your
current Medicaid card to ALL appointments.
*=
* SPECIAL NOTE
*=
* CREDIT CARDS
Please =
check
one of the following payment options below:
_=
__ 1. CASH/CHECK - "I will pay in full when my se=
rvices
are rendered. If glasses or =
other
materials are ordered, I will pay 50% today, an=
d the
balance when I receive them."
_=
__ 2. CREDIT
- "I have previously esta=
blished
good credit in your office. =
I will
pay for my charges in full upon receiving a statement at the end of this
month. I understand that a
rebilling charge of $2.00/month will be charged after 60 days past due.&qu=
ot;
___ 3. MEDICARE PART B.
_=
__a. DEDUCTIBLE NOT=
MET -
"I have not paid out the entire Medicare deductible this year, so I w=
ill
pay for my services in full on the day I receive them as is stated in Opti=
on #1
above."
___b. DEDUCTIBLE MET - "I have met my Medicare deductible this year, so I will pay f=
or
those services that we do not expect Medicare to pay. I will pay them promptly accordin=
g to
the instructions of the office receptionist."
NOTE:
Our office is not required to wait for the secondary Medicare insur=
ance
carrier to pay before billing you directly for the unpaid balance. If you have had cataract surgery,=
then
one pair of glasses is covered after each surgery.
_=
__ 4. VSP - "I have Vision Service Plan (VSP=
). I will pay in full today for any
deductible(s) and extra charges that I owe."
_=
__ 5. MEDICAID. “I understand that if
Medicaid does not pay for any of my services or materials, I am responsibl=
e and
agree to pay for them myself.”
___ 6. OTHER VISION INSURANCE
___a. "I have previously filed this vision insurance plan in this o=
ffice
and we are familiar with the insurance benefits and payments. I agree to pay the remainder in f=
ull
when my services are rendered."
___b. "I have not previously filed this vision insurance plan in th=
is
office; therefore, we are not familiar with the insurance benefits and
payments. I agree to pay for=
all
charges in full when my services are rendered as is stated in Option #1 ab=
ove,
and will request that the insurance payment come directly to me. If it goes to this office instead=
, they
will promptly refund me."
=
c. Name=
of your
Insurance Company:___________________________________________
=
BE SURE=
to
bring your insurance card to your appointment; we will need to make a copy=
of
it. Thank you!
=
I
agree to pay all of my charges as promised. I further agree upon default to p=
ay 1.5%
per month (18% per annum) on any unpaid balances along with all costs of
collection including reasonable attorney fees. I further agree that any dispute =
with
regard to payment of this debt shall be subject to the laws of the State o=
f
________________________________________________ =
; _______________________
&=
nbsp; =
; Patient's
signature =
; &=
nbsp;
=
; &=
nbsp; &nb=
sp; Date