I hereby agree to accept full financial responsibility for the following medical care received from The South Eastern Eye Center which is a non-covered service based on my current insurance benefits according to my policy. Your signature below acknowledges the fact that you have been told prior to any of the following services being completed that they may or may not be covered by your insurance.
● Contact lens fitting ($55-$75) for soft contacts, price to be determined for hard contacts.
● Contact lens re-fit ($25)
● Full examination with discount ($75-$90)
● Co-payments, deductibles, co-insurance and any unpaid amounts by insurance
● Office visits (starting at $50)
● Refraction ($45)
● No Call/No Show Fee/ Missed Follow up Fee ($25)
● Eyewear prescription request service fee ($30)
● Any other service not covered by your insurance that you have been verbally informed of prior to the service be rendered listed here-in or not listed here-in.
These non-covered services will be rendered to you on this day as notated with your signature or your guardians signature below.
Additional Notes for Tricare Beneficiaries
● Tricare Prime/Select (Active Duty Soldiers) - All services are cash pay. In order to use your benefits, you would need to schedule an appointment at Winn Hospital or the TMC, all contact lens fittings are completed at our facility.
● Tricare Prime (Active Duty Dependents) - Coverage for 1 comprehensive eye exam every year. Excluding Contact lens fittings.
● Tricare Prime (Retiree and Dependents) - Coverage for 1 comprehensive eye exam every 2 years unless you have a referral from your PCM.
● Tricare Select (Active Duty Dependents) - Coverage for 1 comprehensive eye exam every year; however, patient must meet all deductibles and pay all cost shares that apply.
● Tricare Select (Retiree and Dependents) - Coverage for 1 eye evaluation per year. Tricare payment if medical diagnosis found. If no medical diagnosis found the patient is responsible for the cost of the exam.
● Tricare for Life/Medicare - Coverage for 1 eye evaluation per year. The exam follows Medicare guidelines. A $45 refraction cost is billed to patient after sent through insurance first.
● Tricare Prime/ Select (Active Duty Deceased Family Member) - Coverage is the same as Active Duty Dependents as listed above for up to 3 years after death. After 3 years, plan shifts to Retiree status outlined above.
Your claim will be denied by Tricare if:
● You are out of your region
● You have multiple insurances
● You have not updated your information in DEERS
● You have services performed before your eligible date, if applicable.
Please note: Insurance may only cover part of your charges or may be payable directly to you. Please give any forms or insurance cards to the receptionist to process your claim. If your insurance company does not pay as expected, you are ultimately responsible for all charges. Filing your insurance is a courtesy service we provide to our patients.
Your signature below shows your understanding and acknowledgement of our office HIPAA documentation. *This signature also authorizes the release and payment of any medical or other information to process claims filed pertaining to services rendered at this office. I understand and agree that professional services are NONREFUNDABLE.
A service charge of 1.5% per month, 18% APR may be added to overdue accounts. You will also be liable for legal and collection cost.
*Your signature below is also acknowledgement of the fact that you have been given the right to review a copy of our office’s HIPAA document.
Your signature below is proof that you have provided our staff with ALL insurance documentation for ALL insurance(s) you have at the time of this visit. Your signature is an indication that you understand that with-holding insurance information for avoiding co-payments, deductibles, or other reason can be deemed fraud by outside entities and may result in legal action against you or your sponsor. Willingly having other health insurance (OHI) and not using it is unacceptable insurance practice and may result in improper insurance claim submission and you paying for your exam out-of-pocket. PLEASE present ALL insurance information to the receptionist.