Please read the following paragraphs and sign below :
Federal statutes require all physicians who participate in the Medicare and Medicaid programs to collect from patients regardless of insurance carrier, any outstanding balances payable to the physician as set forth by their insurance policies. Furthermore, all services may not be covered under your insurance policy. a "refraction" is required to prescribe glasses. In children, this service is a medically necessary part of a complete eye exam. It is most often not considered part of medical care and falls under vision or routine eye coverage** and may be refused by your medical insurance policy. Unless verified by the insurance company prior to your office visit, the refraction fee of $60.00 is payable at the time services are rendered. In children, it is usually the reason for the office referral.
*Please note: your routine vision plan coverage is often separate from your medical insurance plan, and two insurance companies can not be billed for services on the same day.
During your first visit and your complete exams, dilating drops are used to enlarge the pupils of the eye to allow visualization of the inside of your eyes and to perform refractions in preverbal children. Dilating drops blur vision and make bright lights bothersome. Driving may be difficult immediately after the examination; it's best if you make arrangements not to drive yourself. Adverse reactions may be triggered by dilation in susceptible individuals. These side effects are extremely rare and can be treated with immediate attention. In children, dilating drops may cause facial flushing, skin rash, or increased irritability.
I AUTHORIZE PAYMENT TO THE DOCTOR FOR THE SURGICAL AND/OR MEDICAL BENEFITS PAYABLE UNDER THE TERMS OF MY INSURANCE. I ALSO UNDERSTAND AND AGREE THAT FULL PAYMENT FOR MEDICAL AND OPTICAL SERVICES PROVIDED IN THIS OFFICE FOR MYSELF AND/OR MY DEPENDENTS IS DUE AND PAYABLE AT THE TIME OF SERVICES UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE. I ALSO UNDERSTAND THAT I AM RESPONSIBLE FOR ALL DEDUCTIBLES, COPAYMENTS, CO-INSURANCES, AND NON-COVERED SERVICES (INCLUDING REFRACTIONS) NOT PAID BY MY INSURANCE COMPANY. THERE WILL BE A $35 SERVICE CHARGE FOR ALL RETURNED CHECKS, NONSUFFICIENT FUNDS, AND CREDIT CARD CHARGEBACKS. THERE WILL BE A NON-CANCELLATION FEE OF $35.00 FOR APPOINTMENTS NOT CANCELLED 24 HOURS IN ADVANCE. THERE WILL BE A CHARGE FOR ALL MEDICAL RECORDS REQUESTS, AND A $25 FEE FOR ANY REQUESTS OF FORMS NEEDING COMPLETION. AUTHORIZATIONS THAT REMAIN UN-UTILIZED AND REQUIRE OUR OFFICE TO MAKE A NEW REQUEST WILL INCUR AN ADMINISTRATIVE FEE OF $35.00. ACCOUNTS DELINQUENT OVER 90 DAYS WILL BE AUTOMATICALLY REFERRED TO A COLLECTION AGENCY. IF THE AMOUNT OWED IS NOT FULLY SATISFIED BY THE DUE DATE, THEN A FEE OF 35% OF THE OUTSTANDING BALANCE (AS CALCULATED ON THE DUE DATE) WILL BE ADDED TO THE OUTSTANDING BALANCE.
Assignment of benefits: I hereby authorize payment directly to Garima lal, md/pediatric eye associates, inc. of any and all medical benefits applicable and otherwise payable to me. I understand that I am financially responsible to the pediatric eye associates for charges not covered by this assignment.