Insurance:  As a courtesy to our patients, we will gladly file the forms necessary so that you receive the full benefits of your medical coverage.  We ask that you read your insurance policy to be fully aware of any limitations of the benefits provided.  If you are concerned about coverage for any of our services, please contact your insurance company prior to your visit.  You are responsible for supplying the practice with all insurance information - including primary and secondary insurance coverage.  If your insurance company denies coverage, or we otherwise do not receive payment 60 days from filing your claim, the amount will then become due and payable by you.  Remember that your coverage is a contract between you and your insurance company and/or your employer and your insurance company.  Although we will make a good faith effort to assist you in obtaining your benefits, we cannot force your insurance company to pay for the services we have provided to you.

Assignment and Release:  I authorize payment to be made directly to Metropolitan Pediatric Ophthalmology by my insurance company and I accept financial responsibility for all services not covered by my insurance.  I authorize release of any medical care information requested by my insurance company. 

Patient/Parent/ Guardian Responsibility: 

• I understand that whoever accompanies my child to their appointment has authorization to consent to medical care as needed, and is responsible for payment of medical services
• I acknowledge my responsibility for payment of all services provided by Metropolitan Pediatric Ophthalmology in accordance with the practice’s fees and terms.
• In the cases where a parenting plan exists, the parent that brings the child in for the appointment is considered the guarantor and responsible for payment
• At the initial visit, you may sign our consent for minor treatment form that allows us to render care at follow-up visits without the presence of a parent or guardian

Financial Arrangements:  Because we realize that every person’s financial situation is different, we provide a variety of payment options.  For your convenience, we accept all major credit cards and checks.  If the check is returned for any reason, you will have 7 days to contact our office and arrange another form of payment.  All returned checks are subject to a $35 returned check fee.

Credit Card Policy:  All new patients and existing patients will need a credit card on file to process copays, deductibles, non-covered charges, no show/cancellation fees and outstanding balances.  The credit card information will be tokenized for anonymity and held in our system.

If there is an account balance, you will receive a statement in the mail.  If we do not receive payment for the amount listed on your statement within 30 days, we will run the credit card on file for the full amount owed.

I give Metropolitan Pediatric Ophthalmology permission to charge my credit card for any patient balance due on my account.  If I have insurance coverage, my card will be charged AFTER my insurance has paid their portion.

Missed Appointments:  Metropolitan Pediatric Ophthalmology requires 24 hour advance notice for all missed, cancelled or rescheduled appointments.  Failure to notify our office will result in a $35 fee.  Emergencies will be considered on a case by case basis for waiver of this fee

HIPAA/ Patient Consent Policy:  I have read a copy of Metropolitan Pediatric Ophthalmology’s Notice of Privacy Practices.  I understand a written copy will be provided to me at any time upon my request.  The notice can be accessed at any time through our website www.pedseyesite.com.