MONTGOMERY EYE PHYSICIANS & SURGEONS
OFFICE POLICY & FINANCIAL RESPONSIBILITIES
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APPOINTMENTS:
We request that you keep scheduled appointments and arrive at the scheduled time. If you are unable to keep your appointment, please give at least 24 hours’ notice so that we may offer that time to another patient. Cancellations of less than 24 hours prior to your appointment, or a No-Show for your appointment, will result in a $50.00 fee. If you are late to your scheduled appointment, we will make every effort to accommodate you. However, we may need to reschedule your appointment.
INSURANCES & PATIENT PAYMENTS:
Your claim will be submitted to the insurance that we have on file. It is your responsibility to submit all relevant medical insurance information to us and update it as it becomes necessary. We have no control over how your insurance company processes its claims or if and how much they may pay on a claim. You are ultimately responsible for knowing your benefits and the terms of your coverage. Any amount that is not covered by your insurance is your financial responsibility and you will be billed accordingly.
Copay and any selfpay feesare due at the time of service. If these are not paid before leaving the office, we reserve the right to add an administrative charge of to your account in order to defray the cost of obtaining the copay/fees.
Unfortunately, we DO NOT participate with vision insurance plans. We can check/dispense a glasses prescription (refraction) for you and submit the claim to your medical insurance. However, Medicare and most commercial insurances do not cover this fee. Payment for a refraction is due at the time of service unless we have evidence that your insurance has paid in the past.
ACCOUNT BALANCES:
Any balances that are past due will be assessed a service charge of submitted to a collection agency, a collection fee (30% of the outstanding balance) will be charged to the account. The collection agency will report any unpaid balance to the major credit card bureaus. If for any reason, the account is litigated, you will also be held accountable for all attorney costs and court fees. Fees are subject to change; in that event, you will be notified of such changes.
In the event that this balance should be submitted to a collection agency, a collection fee (30% of the outstanding balance) will be charged to the account. The collection agency will report any unpaid balance to the major credit card bureaus. If for any reason, the account is litigated, you will also be held accountable for all attorney costs and court fees. Fees are subject to change; in that event, you will be notified of such changes.
RETURNED CHECKS:
Any payment made by check that does not clear your bank account will result in a fee for insufficient funds. Our fee is $30.00 and will be added to your account for each returned check.
REFERRALS:
If your insurance plan requires a referral, it must be presented before seeing the physician. If you do not have the required referral, we reserve the right to reschedule your appointment.
FORMS:
There is a $25 fee for any forms that need to be completed by the office. MVA or driver’s license renewal forms will be waived if completed at the time of your appointment.
The physicians and staff at Montgomery Eye Physicians & Surgeons appreciate your confidence in allowing us to participate in your eye care. Your signature indicates that you have read, understand and agree to our office policy & financial responsibilities of our office.