If we participate with your insurance carrier, we will accept assignment on all covered services and bill your insurance for you. You are responsible for the copay, deductible, and all non-covered services. Depending upon your particular benefits package with your insurance, they may cover some, all, or none of the services rendered to you.
Therefore it is your responsibility to:
1. Provide documentation of your coverage
2. Know what benefits are covered by your insurance and what services are your personal responsibilities.
3. Provide the appropriate documents (e.g. referrals) that allow us to bill your insurance carrier. If the appropriate information is not received, you will be asked to sign a waiver of responsibility.
We accept Medicare assignment, which means that we accept the allowable charges set by Medicare. Medicare typically pays 80% of the allowable charge after your deductible has been met. You will be responsible for the 20% remainder unless you have a Medicare supplement. We will bill your Medicare supplement after Medicare has paid, if you provide the necessary information to us.
Rarely, after complete healing from surgery for which insurance has paid, you and your surgeon may agree that some revision procedure would enhance your cosmetic outcome. I understand that aesthetic surgery is not a covered benefit of Medicare and other insurance carriers. Therefore any aesthetic procedure will be my financial responsibility and payment in full will be expected prior to the procedure.
Medical Authorization Release
By signing below, you authorize Fante Eye & Face Centre to give you reasonable and proper medical care by today’s standard.
I agree that the attending physician may use, or permit other persons to use any negatives, prints, movies, and digital images, and/or other visual or audio recordings, for purposes including, but not limited to, dissemination to health care professionals and/or members of the public for treatment, research, medical, scientific, teaching, or other purposes in such a manner as may be deemed appropriate by my attending physician. I agree that this information may be disseminated in either paper form or digital form using delivery techniques that include but are not limited to the U.S. Postal Service, Federal Express, UPS, email, the Internet, and file transfer protocol.
I hereby authorize Fante Eye & Face Centre to release any medical or other necessary information to insurance carriers in either paper or digital from concerning this illness/accident. I hereby irrevocably assign all payments for all services rendered to Fante Eye & Face Centre. I also request payment of government benefits either to myself or to Fante Eye & Face Centre. I have read and understand the policies described above. I have provided complete and accurate medical and financial information on all forms. I acknowledge that I am responsible to pay all charges for treatment as outlined above.
A copy of this authorization shall be considered valid as the original.