We would like you to know about our office policy on billing. The more you know, the more we can be of service to you. If you have any questions, please ask at any time.
Due to the increased cost of providing medical care, we ask that you pay your co-payment on the same day the services are provided. Co-insurance and deductibles can be billed after service, but the practice may ask you to pay a portion upfront. We understand that situations arise when you may not be able to pay. In this case we ask that you speak with our Billing Department to make arrangements.
If we suspect that your insurance company will not cover a service, we may ask that you sign a form in advance acknowledging that you have been advised of this and accept financial responsibility. You can decline to sign and refuse the services. In addition, we ask that cosmetic surgery, refractive surgery (such as LASIK), and elective procedures be paid prior to services being performed.
Our office will bill all covered services to a Primary and Secondary Insurance. We do not bill more than two insurance carriers. We give insurance carriers a maximum of 60 days to pay the claim. Failure to process the claims in a timely manner may result in it being turned over to the patient's responsibility.
Our staff will try to verify that every patient on an HMO plan has a referral on file for their visit. However it is the PATIENT'S responsibility to obtain one. Patients that are seen in our office with an HMO policy should bring a referral / authorization with them at every visit. Please feel free to call our office before your appointment to make sure we have your authorization on file. Failure will result in insurance non-payment, therefore you will be responsible for all charges on that visit.
Please understand that appointments are limited. If you must cancel, we request 24 hours notice.
No show appointments or cancelling / rescheduling inside of 24 hours will
incur a fee of $25. Returned checks will also incur a fee of $25.
I transfer the rights and benefits contained in this policy to Champion Eyecare, including the right to act as my authorized representative during an appeal, the right to file suit, and the right to obtain disclosure of the insurance plan description or policy.
I have read and understand the above document.