Practice Policy

1. All account balances need to be paid in full before any optical products can be purchased.
2. Failure to call or no-showing of an appointment will result in administrative fee of $25 that is not billable to insurance. Noshowing a surgical or dry eye clinic appointment will result in a $75 fee. The staff member spoken to as well as the date and time of the call must be presented as proof in order to dispute a no-show charge.
3. All appointments have a 10-minute grace period for tardiness, any patient over 10 minutes late may need to be rescheduled.
4. FSNEC does its best to make courtesy phone calls to remind patients of upcoming appointments but are sometimes unable to provide such services. Lack of a reminder phone call does not cancel the above no-show policy.
5. There will be a fee for each form that needs to be filled out by FSNEC office staff. These fees will be determined based on the complexity and requirements of the form. The form completion process may take up to 14 days.
6. Following the guidelines of the Illinois General Assembly, there will be a fee for the copying of medical records. Records released to the patient will incur a $25 fee payable by the patient or responsible party. Records released to another provider’s office will be no charge as a courtesy to the patient. The records release process may take up to 14 days.
7. All prescription refill requests need to be faxed to FSNEC by the pharmacy in which the patient wishes to use.
8. It is the responsibility of the patient/parent/guardian to remain compliant with the doctor’s treatment plan. FSNEC will not be held responsible for patients that are not compliant with their treatment plans.
   a. Patients who routinely no-show and cancel appointments may be released from care due to non-compliance.
9. FSNEC does its best to provide and positive and safe environment for both its patients and its staff members. We strive for excellence and treat patients and staff with respect. With this being stated, any abuse of fellow patients or of staff members, whether it be physical or verbal (use of foul language, threats, name-calling, etc.) is grounds for the immediate termination of care.

Here at Fisher-Swale-Nicholson Eye Center, we are committed to providing you with the highest level of service and quality care. If you have medical insurance, we will strive to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and understanding of our financial policy. Ultimately, however, all financial liability rests with the patient.

Our office participates with most major insurance plans. We provide MEDICAL and SURGICAL ophthalmologic care to our patients. FSNEC does not participate with ANY vision plans and will not bill any charges to these plans. Patients may choose to have FSNEC utilize the Anagram system when making optical purchases to submit purchase receipts to their vision plans in order to utilize their out-of-network benefits and be reimbursed by their vision insurance plan directly. Detailed receipts will be mailed to patients upon request if they choose to submit for reimbursement on their own.

If you have a managed care plan (HMO) that requires a referral/authorization to see a specialist, you must obtain a referral/authorization in order for your visit at our office to be covered under your medical insurance. If the proper documentation has not been obtained, the appointment will be rescheduled after we receive these
documents. Any claims denied for lack of referral/authorization will be the patient’s/parent’s/guardian’s responsibility. If you do not have the valid referral/authorization and still wish to be seen, you will be asked to
pay for the visit prior to your examination & to sign an agreement to be self-pay.

A refractive examination is not a covered service by most insurance companies, including Medicare. If you are here for an exam, you will be charged $45 for the refraction, which is an important part of your exam and is payable at the time of the visit.

It is the patient’s/parent’s/guardian’s responsibility to:

1. Be familiar with the benefits of your insurance plan, including co-pays, co-insurance and deductibles, as well as covered benefits such as routine eye exams and your doctor’s network status with your insurance.
2. Bring all of your current insurance cards to all visits.
3. Provide our office with current information including providing Fisher-Swale-Nicholson Eye Center (FSNEC) with current insurance information, address, phone number and email.
     • Any claims denied for insufficient/incorrect information will be the
        patient’s/parent’s/guardian’s responsibility.
4. Co-Pays, deductibles, account balances and refraction charges are due at the time services are rendered or the appointment may be rescheduled. Please be aware that payments collected for deductibles, coinsurance and procedures are estimates. Accounts will be reconciled after claims have been processed. Any remaining balances may be billable to the patient. In the occurrence of an over-payment a refund
would be issued to the patient.

We appreciate prompt payment in full for any outstanding balance. Payment is due upon receipt of the statement. We offer payment plans and auto-deduction options to assist you in managing your financial responsibilities. If an account balance goes 60 days with no correspondence from the patient, FSNEC will assume there is no intention to pay the balance and the account will then be placed for collections. If FSNEC is forced to turn the account over for collections the responsible party will be accountable for any additional collection fees incurred.

Any check payments that do not clear the bank will be subject to a $25.00 non-sufficient funds fee and your account will then be placed on a cash/card only basis moving forward.

Our Notice of Privacy Practices (updated 2021) provides information about how we may use and disclose Protected Health Information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office or visiting our website at www.fisherswale.com.

You have the right to request that we restrict how Protected Health Information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, except in certain limited instances, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of Protected Health Information about you for nonsubsidized treatment, payment and health care operations, and for other purposes as permitted or required by law. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

• Protected Health Information may be disclosed or used for treatment, payment or health care operations, or for other purposes permitted or required by law. However, we will obtain from you a separate written authorization for “subsidized” disclosures, meaning disclosures involving product or service with respect to which the Practice receives remuneration from a third party.
• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
• The Practice reserves the right to change the Notice of Privacy Policies.
• The patient has the right to restrict the uses of their information, but the Practice does not have to agree to those restrictions, except in certain limited instances.
• The patient may revoke this Consent in writing at any time and all future disclosures will then cease.
• The Practice may condition treatment upon the execution of this Consent.

Please list any individuals below that you would like to be authorized to access your PHI.

By signing below, I agree that I have read and understand the above Financial, Practice and HIPAA policies.