Patient Registration Form - Chester County Eye Care (Page 2 of 2) in pdf

PATIENT FINANCIAL RESPONSIBILITY POLICY FORM

Thank you for choosing Chester County Eye Care Associates as your eye care provider. We are honored by your choice

and are committed to providing you and your family with the highest quality eye care. We ask that you read and sign

this form to acknowledge your understanding of our patient financial policies.

INSURANCE COVERAGE

It is your responsibility to be aware of your insurance coverage, policy provisions, exclusions and limitations as well as

authorization requirements. This information is furnished by your insurance company. If your insurance requires a

referral, it is your responsibility to obtain one prior to your visit. If you do not have one, you may sign a waiver stating

that you will be responsible for payment in full if the referral is not received within one day. Alternatively, you may

reschedule your appointment.

Just as we make every effort to accommodate you when you are in need of eye care, we expect payment in full on

receipt of your billing statement. The statement will reflect the amount you owe after your insurance has processed

your claim. If no resolution can be made within 30 days, the account will be sent to the collection agency and dismissal

from the practice may be initiated.

INSURANCE PAYMENTS SENT TO YOU

If insurance payments are sent to you, you are responsible for forwarding these payments to our office with a copy of

the Explanation of Benefits received from your insurance company.

INSURANCE CHANGES

If you have had any changes in your coverage, please notify us. Even a small discrepancy can lead to a denial of

payment.

CO-PAYMENTS, DEDUCTIBLES, CO-INSURANCE AND PAST DUE BALANCES

All co-payments are collected at the date of service. If, for any reason, the co-payment is not collected at the date of

service, we will charge a fee of $11.50 to cover our cost of creating and sending an invoice to you.

Past due balances are due at the date of service unless previous arrangements have been made with an insurance

counselor.

Insurance deductibles and fees for service not covered by your insurance policy are due at the time of service.

An example of a non-covered service is REFRACTION (unless you have a vision plan). REFRACTION is a procedure

necessary for eye doctors to evaluate your vision and/or write glasses prescriptions. Unfortunately, many insurance

companies, including Medicare, do not cover this procedure. Our fee for this service is $45, and is expected at the time

of check-out. This fee is subject to change.

Our office accepts VISA, MasterCard, American Express, Discover, cash, money orders and checks. No post-dated

checks will be accepted. Any bounced check will incur a $35 charge.

SELF PAY PATIENTS

You are responsible for your payment in full at the time of service.

FAILURE TO PAY

Patients who ignore collection notices or fail to pay their balances risk negative credit ratings and possible dismissal

from the practice.

MISSED APPOINTMENTS

If you need to cancel an appointment, we ask at least 24 hours notice. This allows us to offer the appointment to

another patient. If multiple appointments are missed without notice to us, you may be discharged from the practice.

We hope this clarifies any issues you may have about our office financial policies. Signing below verifies that you have

read and understand this form and that you will abide by the policies stated. Please feel free to ask our insurance staff

any questions about our policies.

Patient Name

Patient/

(please print):_________________________ Custodian Signature:_________________________ Date:____________

Patient Registration Form - Chester County Eye Care Page 2

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