Patient Financial Responsibility Policy

Patient Name:

Date of Birth:

Insured Name:

Date of Birth:

Address Change

It is important that we have your correct address information on file. Please advise us anytime there is any change to your address, telephone or other contact information.

Co-payments, Deductibles and Co-Insurance

Co-payments are collected at the time of check-in.
Insurance deductibles and fees for services not covered by your insurance policy, if known, are due at the time the service is rendered. We accept cash, check and most major credit cards.

Billing

If you owe additional money after your visit, you can expect to receive a statement. Statements are mailed out on a monthly basis.

Failure to Pay

Patients who ignore collection notices and fail to pay their balance risk negative credit ratings and possible dismissal from the practice.
Past Due accounts may hinder your ability to have appointments scheduled.

Self-Pay Patients

Fees

Returned checks are subject to a $32 fee and your account will be placed on a "cash-only basis." We will accept payments only by cash or credit card until the balance is cleared.
Failure to give 24 hours cancellation notice or failure to keep your scheduled appointment may result in a charge of $30. Missed appointments represent a cost to us, to you, and to other patients who could have been seen in the time set aside for you. We reserve the right to charge a fee for canceled or missed appointments. If you must cancel an appointment, Vision Park requires a minimum of 24 hours' notice.

Guarantor

Any patient over the age of 18, or an emancipated minor, will be held financially responsible for all charges incurred. If another party is responsible for the payment of your account, you must pay your balance in full and negotiate repayment with them outside of our office. This policy includes individuals negotiating divorce agreements.

Referrals and Authorizations

Please be aware of and provide any required referrals or authorizations in advance of the appointment of service. If you do not provide these before care is provided, you will be responsible for the cost of the care. When in doubt contact your plan directly for clarification.

Medicare Patients

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