FINANCIAL POLICY

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Thank you for choosing our medical practice. We are committed to providing you with the best possible medical care. The following information is provided to avoid any confusion regarding payment for medical services. As a courtesy, our Insurance Billing Department will file claims with your Medical Insurance. We do not accept Vision Plans. Your Medical Insurance will only pay for services that are covered by your policy. It is your responsibility to pay for services that are not covered or are declined by your insurance.

The following items must be paid at the time of your visit:

• “Routine” or “check-up” or “glasses” eye examinations without any medical reason ($240)

• Co-payments

• Deductibles which have not been met

• Co-insurance amounts (this means your insurance only pays a portion, such as 70%)

• Refractions: Refractions (checking or updating glasses prescription) are not covered by most insurance companies. We charge $40 for refraction, in addition to the office visit fee.

We accept cash, most debit cards, Visa and MasterCard. There is a $75 charge for no-shows, missed appointments, canceling or rescheduling appointments with less than 24 hours notice.

Following your visit, you may receive an invoice for any services which your insurance did not cover. This can take up to 6 months. If we believe a service should be covered, we will contest any denials.

Account balances which go unpaid for 90 days or more will be assessed a $10 re-billing fee for each statement generated. After 120 days, the account will be turned over to a collections agency, and a $40.00 fee will be added. To avoid additional charges associated with unpaid balances, we recommend an optional credit card payment plan that we will use for settlement of any unpaid account balances:

I authorize Jennifer Lin, MD to charge outstanding balances on my account to the following credit card:

INSURANCE ELIGIBILITY GUARANTEE: I understand that if the health insurance information I

have provided is not true, or if the patient is not eligible under the terms of the Medical Subscriber Agreement, I am responsible for any and all charges for services rendered. If the patient does not have health insurance coverage, I agree to pay in full for all services rendered within 30 days of receiving a bill from this office.

RELEASE OF INFORMATION/ASSIGNMENT OF BENEFITS: I hereby authorize the release of any medical information necessary to process insurance claims and authorize payment of benefits to Jennifer Lin, MD.

I certify that I have read and fully understand and accept the above financial policy.