At the Eye Institute of South Jersey, PC, providing excellent eye care within the guidelines of your insurance plan is our primary focus.  As a service to our patients our doctors are enrolled in numerous insurance companies. Within each insurance company there are many plans that are available for employers or individuals to choose from and one plan may differ greatly from another with the same or similar name. As a patient, you may see this translated into year to year changes in your copays, co-insurances, deductible amounts and drug formularies yet the plan name may have remained the same or close to the same.  At the Eye Institute of South Jersey, PC, we do our best to stay informed of changes and updates in plans but ultimately it is neither possible nor our responsibility to keep track of all of the nuances inherent to each individual plan.  It is imperative that you know your own insurance plan and its policies to allow us to better serve you and to receive the maximum benefits you are entitled to.

At the Eye Institute of South Jersey, PC it is our vision to advocate excellence in eyecare and to educate and motivate our patients to be proactive in their care.   During an examination, our doctors may diagnose eye diseases and conditions that require them to order additional vision testing, lab tests or the need to perform procedures or surgeries.  If your insurance plan has precertification requirements or requirements as to which facility can perform your tests, procedures or surgeries you must inform us in advance and we will do everything in our power to comply with the parameters of your plan. Unfortunately, if you do not inform us of any special requirements dictated by your insurance plan any charges incurred will become your responsibility.  

If your insurance benefits change and you have not updated our office with current insurance documents or you are not actively enrolled in the presented plan you will be financially responsible for any services you have received.  In any case where you have failed to produce a referral when needed for medical care you are subject to billing for all fees incurred.  If you are examined in our office for a work related, or accident related injury and fail to provide proper documentation and information before and during the examination and/or treatment you will be financially responsible for any non-covered fees. In the event that we are a nonparticipating provider with your insurance company, you will be responsible for any balance left unpaid by your insurance.

All copays, co-insurance payments, deductibles and self-pay payments will be collected at the time of service.  For your convenience our office accepts cash, checks, money orders, Visa credit and debit cards, MasterCard and Discover cards.  A copy of a valid driver’s license will be required to write checks in our office and may be requested for presentation when a credit card is used. Please note that we do not keep credit card information on file.

Any patient who is 17 years of age or younger is considered a minor in our office and will be required to have their parent’s signature on their financial responsibility form.

Authorization for Services:

I hereby authorize the Eye Institute of South Jersey, PC and its providers to bill my insurance company, which may include the release of my confidential medical Information to process the claim.

I authorize direct payment to the Eye Institute of South Jersey, PC, David R. Pernelli, MD or

Terrance K. Heacox, Jr, OD as contracted by my insurance plan.

I have received and/or read the “Office Policy Regarding Financial Responsibility” provided to me by the Eye Institute of South Jersey, PC. and understand and agree to the policy in its entirety.