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Patient Financial Agreement

Patient Financial Agreement

PATIENT FINANCIAL RESPONSIBILITY AGREEMENT

Thank you for choosing us for your eye care needs. We would like to provide you with a clear understanding of our financial agreements and billing procedures in the hopes of preventing misunderstandings and keeping costs down for everyone.
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Payments

  • We accept cash, checks, Visa, Mastercard, Discover, American Express and Apple Pay

  • Most eye care materials and services are FSA/HSA card approved. Please check your plan

  • Payments for materials and services are due at the time of service.

Insurance & Vision Plan Patients


YOUR BENEFITS:

It is your responsibility to read and understand your contract and benefits that are available to you from your insurance company. We will estimate your coverage as a courtesy to you.


INSURANCE CARD:

If you do not provide your insurance card or proof of insurance, payment-in-full is appreciated and expected at the time of service.


BILLING:

As a courtesy to you we will file insurance claims for services we provide. It is your responsibility to make sure your insurance company pays towards these claims. We are not always given all patient financial responsibility information like co-insurance and deductibles when the order is placed. Your insurance contract states that you guarantee payment and insurance preauthorization is not always a guarantee of benefits.

BILLING QUESTIONS:

We always bill usual & customary pricing. Based on your contract with your insurer, your insurer determines what they will pay and what you owe. If you have questions about what was paid and what you owe, please contact your insurer directly. If you have questions about what was billed, please contact our office.

PAYMENT:

We will ask you to keep a credit/debit card on file in our secure online system for services billed to your insurance. Once the claim has been processed, your card will be charged for any remaining patient responsibility as deemed by your insurer. These amounts can be found on your insurer’s EOP (Explanation of Payment) mailed/emailed to you after your claim is processed. As guarantor, if you don't wish to keep a card on file, you may be required to pay in full for your visit and be refunded the difference of your insurance payment.

CO-PAYMENTS/CO-INSURANCE:

After your insurance is billed, your card on file will be charged for any unpaid copays or coinsurance amounts on the insurer’s explanation of payment.

DEDUCTIBLES:

Likewise, after your insurance is billed, your card on file will be charged for unmet deductible amounts listed on your insurer's explanation of payment.


General Policies

  • There is a $40 fee for returned checks.

  • If third-party collection becomes necessary, you agree to pay all reasonable collection costs & attorney’s fees.

  • We request 24-hour notice for appointment cancellation. If you do not provide 24 hour notice, you may be charged a $25.00 fee.
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